There is no cure for osteoarthritis and most treatment is concerned with helping patients manage the associated pain and inflamation. Because everbody experiences osteoarthritis in different ways, it is impossible to recommend one particular drug over another. Most of the current thinking would suggest that a combination of pharmacalogical and non-pharmacological treatments should be used. In our self care and coping skills pages we set out some of those interventions which have some part to play in lessening the effects of this complex condition. This page is devoted to pharmacological treatments and surgical procedures. The Medscape site identifies the prevention and correction of deformity and the "amelioration of the destructive process" as the two other goals of treatment but notes that our ability to achieve these goals is quite limited
Paracetamol
Doctors are encouraged to use paracetamol first as it is an effective pain killer and has few side effects. The European League Against Rheumatism (Eular) guidance on OA of the hip states that "Because of its efficacy (effectiveness) and safety paracetamol (up to 4g per day) is the oral analgesic of choice for mild-moderate pain and, if successful, is the preferred long term oral analgesic."
It is recognised that paracetomol is less effective in relieving pain but is much safer than non-steroidal anti-inflamatory drugs (see below). There has been some concern that use of paracetomol above 2g per day may increase the risk of gastro-intestinal bleeding and/or perforation but a systematic review of the research literature shows that there is no increased risk. The National Institue for Clinical Excellence (NICE) draft guidance states that "The long-term safety data on paracetamol from observational studies is reassuring".
The guidance goes on to recommend that paracetamol should be considered a core treatment for patients with osteoarthritis. It suggests that people should receive regular doses every day rather than just using paracetamol when the pain flares up.
Combined painkillers and opioid analgesics
These (eg cocodamol, codydramol) contain both paracetomol and codeine, the Arthritis Research Campaign says that "they may be stronger than paracetomol but are more likely to cause side-effects such as constipation or dizziness".
The Eular guidance states that combined painkillers should only be used for patients who can't be prescribed with either NSAIDs or Cox2 inhibitors.
NICE recommends that opioid analgesics should only be considered where paracetomol and NSAID creams have proved insufficient. The guidance notes that "Constipation, nausea, itchiness, drowsiness and confusion remain important side-effects to be considered" especially in the elderly.
Non-Steroidal Anti-Inflamatory Drugs(NSAIDs)
NSAIDs are more effective in relieving pain and stiffness than paracetomol. They do however have significant side effects (rashes, headaches, heartburn, indigestion, stomach upsets). Long term use can also lead to the lining of the stomach being damaged and to gastro intestinal bleeding. You should not take NSAIDS if you have a history of indigestion or stomach ulcers. Some doctors will also prescribe proton pump inhibitors(PPIs) as well as an NSAID to reduce the risk of gastro-intestinal side effects although a recent study has shown that long term use of PPIs is associated with an increased risk of hip fracture .
The National Institute for Clinical Excellence states that "according to some estimates, 2000 deaths due to NSAID related side effects occur each year in the UK."
The NICE draft guidance recommends that "Where paracetamol or topical NSAIDs are insufficient, then the addition of an oral NSAID / COX-2 inhibitor to paracetamol should be considered. Where paracetamol or topical NSAIDs are ineffective, then substitution with an oral NSAID / COX-2 should be considered." and " Oral NSAID / COX-2 inhibitors should be used at the lowest effective dose for the shortest possible period of time."(emphasis added)
NSAID creams, gels and ointments.
NSAID creams and gels are considered effective with knee and hand OA. These are said to be very safe, the risk of side effects is much reduced as very little is absorbed into the bloodstream.
The NICE guidance identifies short term (up to 4 weeks) benefits in using these with knee osteoarthritis. These topical treatments are considered to have far less risks than oral NSAIDs and the guidance recommends that they should be a core treatment for knee and hand osteoarthritis.Cox-2 Inhibitors
These are a type of NSAID that block an inflamation-promoting enzyme called COX-2(cyclo-oxygenase-2).
Cox-2 inhibitors had fewer gastro-intestinal side effects and were recommended for use in people who may be at high risk of developing serious gastro-intestinal problems. NICE identifies the following groups as being at high risk -Recently Merck has withdrawn its CoxII Inhibitor (Vioxx) from the market after evidence showed an increased risk of heart problems. Merck is currently being sued by 30,000 people in the US who claim that their heart problems were caused by Vioxx. Current guidance in the UK suggests that this type of medication should only be given to those individuals who do not have a history of heart problems or those who are not considered to have an increased risk of heart disease.
This issue is very complex, if you have any concerns about your medication you should discuss these with your GP. The British Medical Journal has published an overview of the Vioxx controversy.
Medscape notes that "COX-2 inhibitors are not free of upper gastro-intestinal and renal side effects".
Capsaicin
This is a cream derived from pepper plants which has been shown to be effective in managing the pain associated with affected hands and knees. This may cause a burning sensation in the first few days of treatment but this wears off with regular use. The ARC site says that capsaicin cream needs to be regularly applied each day to be effective. The NICE guidance recommends that capsaicin should be conidered as an adjunct to core therapy for knee and hand osteoarthritis.
Steroid Injections.
Steroid injections are usually used for patients with severe pain, they are said to be effective in knee, hip and thumb joints. The pain is usually reduced within 24 hours of the injection. The risks associated with steroid injections are said to be small and there is only a very small risk of infection
The NICE guidance recommends that steroid injections "should be considered as an adjunct to core treatment for the relief of moderate to severe pain.
Long-term use of steroid injections can lead to higher blood pressure, osteoporosis, thinning of the blood and weight gain.
Hyaluronan Injections
Hyaluronan is similar to the viscous material in a normal joint. The Nice guidance comments that the efficacy of hyaluronan injections is difficult to interpret and does not recommend their use.
Surgery
Surgery is used for people with hip or knee osteoarthritis whose joint is badly damaged.
The NICE guidance states that surgery is "performed in the vast majority of cases for pain which originates from the joint, limits the patient’s ability to perform their normal daily activities, disturbs sleep and does not respond to non-surgical measures. Joint replacement is very effective at relieving these symptoms and carries relatively low risk both in terms of systemic complications and suboptimal outcomes for the joint itself. Joint replacement allows a return to normal activity with many patients able to resume moderate levels of sporting activity including golf, tennis and swimming."
In total hip replacement the top of the thigh bone is removed and a new smaller artificial ball is fixed to the top of the thigh. The socket in the pelvis is fitted with a new artificial socket. The replacement parts can be either plastic, ceramic or metal. The most commonly used combination is a metal ball with a plastic socket although younger and more active patients may be given a ceramic ball with plastic socket.
A less drastic form of hip surgery is metal on metal resurfacing whereby a metal cap is fitted over the head of the thigh bone the socket is resurfaced. This procedure is not appropriate for people with osteoporosis or low bone density.
Knee surgery involves either total knee replacement, unicompartmental replacement or kneecap replacement.
With total knee replacement the upper end of the shin bone (tibia) is replaced by a flat metal plate and the lower end of the thigh bone (femur)is replaced a curved piece of metal. A plastic bearing is fitted to the flat plate and this acts as hard cartilage between the two plates.
Unicompartmental replacement is only suitable for those people who have only one side of their knee affected. This is said to provide better mobility than the total knee replacement and the recovery time is usually quicker.
Kneecap replacement is appropriate if the kneecap is the only part of the whole knee that is affected.
The NICE guidance recommends that "Referral for joint replacement surgery should be considered for patients who experience joint symptoms (pain, stiffness, reduced function) that impact substantially on their quality of life and are refractory (resistant) to non-surgical treatment. Referral should be made before there is prolonged and established functional limitation and severe pain."
