Understanding Arthritis Painkillers

Weighing the Risks and Benefits

From the WebMD Archives

When you have arthritis pain, you need relief. But with so many warnings in the news about painkillers, it's hard to know the best choice. Many medications that ease arthritis pain have the potential for health risks, including increased risk for heart attack, stomach problems, or infections.

You have difficult decisions to make, whether you're fighting pain from osteoarthritis that comes with age -- or pain from rheumatoid arthritis, a debilitating immune disorder. Do you somehow tough out the pain? Or do you accept the risk because your pain requires it, and take the drug for arthritis? Which drug is right for your body? And which medicine may work best for your type of arthritis?

First, says Patience White, MD, chief public health officer for the Arthritis Foundation, it's important to keep in mind that the risks of arthritis drugs are really quite low. "There are risks," she says, "but depending on the drug you may have a greater chance of getting hit by a car crossing the street than having side effects of the drugs we're talking about."

Second, many people with arthritis need pain relief in order to go about their daily lives and get the exercise that could improve their condition.

Easing arthritis pain can help someone with osteoarthritis "get up and going, and get walking," White tells WebMD. "If you have osteoarthritis, losing 15 pounds will stop the progression of your disease and reduce your pain. Then you can quit taking the pain medication!"

Although pain from rheumatoid arthritis cannot be reduced through weight loss, the risk of not treating this immune disease is even more dramatic. Without treatment, RA tends to progress and worsen. New drugs called biologics can stop the damaging effects of the disease. "These drugs carry a slight risk of cancer, because they suppress the immune system," says White. "Yet if you don't take them, you are going to be disabled. You have to put that risk-benefit ratio on the table."

She offers an analogy: Would someone decide against cancer treatment that offers a possible cure simply because they were afraid of chemotherapy drugs?

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Deciding on Arthritis Pain Medicine

White advises people to make their decisions only after talking with a trusted health care provider. Ask key questions so you fully understand the benefits and risks of your medication, says White: "What are my risks? What is the chance this could happen?"

Also, get the emotional and practical support you need to cope with arthritis pain during treatment, says Nortin Hadler, MD, a rheumatologist and professor of medicine at the University of North Carolina at Chapel Hill, and author of Worried Sick.

Hadler has researched the mind-body connection in arthritis pain, and has found that people who may be lonely or depressed feel pain more acutely.

To help you understand your options, here are common medicines for arthritis pain. Keep in mind, different drugs are often used to treat osteoarthritis, rheumatoid arthritis, and other less common forms of arthritis. This information covers the most commonly prescribed painkillers. Talk to your doctor to learn about more options.

Common Medicines for Arthritis Pain

Acetaminophen

Acetaminophen (also known by the brand name Tylenol) may be used to treat mild arthritis pain from osteoarthritis or rheumatoid arthritis. It can be just as effective as some prescription anti-inflammatory pain relievers for mild pain -- and is easy on the stomach.

Other medications sometimes include acetaminophen as an ingredient, so make sure you don't end up taking too much of it. Overdoses of acetaminophen can damage the liver. People who drink alcohol regularly, or already have a damaged liver, should consult their doctor before taking acetaminophen.

Anti-Inflammatory Painkillers (NSAIDs)

Nonsteroidal anti-inflammatory drugs called NSAIDs help relieve joint swelling, stiffness, and pain -- and are among the most commonly used painkillers for people with any type of arthritis. You may know them by the names such as ibuprofen, naproxen, Motrin, or Advil.

While NSAIDs are reasonably safe, when taken for months or years, they can cause stomach ulcers and may increase your risk for heart attack. Cox-2 inhibitors like Celebrex are more stomach-friendly, but may have a slightly higher risk of heart problems than milder NSAIDs such as ibuprofen or naproxen.

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Recent research also indicates that people who take daily aspirin for their heart should talk to their doctors before taking any NSAID regularly for pain. NSAIDs may alter the effect of aspirin.

But here's the question that White at the Arthritis Foundation tells her patients to ask themselves: "How does a slight risk of heart disease compare to the risk of arthritis pain itself?"

To reduce the chance of side effects, turn to NSAIDs as a short-term solution if possible, says White. Ask your doctor to prescribe the lowest effective dose, or a combination of drugs.

To protect your heart, it also helps to control other risk factors of heart disease such as high blood pressure and elevated cholesterol.

Steroids

Steroids such as Decadron and prednisone are strong anti-inflammatories that calm swelling, inflammation and pain.

For osteoarthritis, steroid injections are primarily injected into the joint for a direct effect on the painful joint. They can also be used for this purpose for people with rheumatoid arthritis.

High doses of steroid pills can be taken temporarily to treat severe flare-ups of rheumatoid arthritis. Low-dose pills may be used longer term to help tame inflammation and pain.

Especially with rheumatoid arthritis, steroids can "make a huge difference," says White. "Steroids decrease the pain and swelling very rapidly." After treating rheumatoid arthritis with steroids, White often follows up with biologic medicines.

However, when taken long-term, steroids can increase a person's risk of infection, increase blood sugar levels, and thin a person's bones. Most doctors recommend steroid pills for short-term use. Steroid injections help avoid side effects outside the joint, and may be used for longer-term use.

Narcotics

Prescription narcotic painkillers -- such as codeine, fentanyl, morphine, and oxycodone -- are used for severe pain that is not relieved with other medications. The drugs work on the nerve cells' pain receptors and are very effective in controlling severe pain.

In rare cases, White prescribes a narcotic for arthritis pain relief, she says. "If the only way to get someone up and out of bed is a mild narcotic, then I'll do it. I do it only to help people get over a hump, and only rarely. There are a lot of side effects."

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Narcotics are particularly dangerous for elderly patients, because of the risk of falls, White adds. "Most people don't want to take narcotics. I don't think it's the dependency issue as much as it clouds their thinking, and they get constipated. There are a lot of issues that people don't want to put up with."

DMARDs (Disease-Modifying Anti-Rheumatic Drugs)

In rheumatoid arthritis, DMARDs such as methotrexate can help prevent the serious joint damage that is caused by inflammation (they are not used to treat osteoarthritis). Because DMARDs take weeks to really start working, steroids or painkillers are sometimes used until they kick in.

"These drugs are revolutionizing the field of rheumatology," White tells WebMD. "They really have something important to offer people, a chance to not be disabled and out of work. They also offer a chance to do basic lifestyle changes that relieve pain."

There is a downside to many DMARDs: They work by suppressing the immune system, so there is greater susceptibility to infection while taking these drugs. Also, there is risk for liver problems, low blood count, and a slightly increased risk of cancer.

White says she advises her patients to weigh the benefits versus the risks. A person with painful progressive rheumatoid arthritis could face serious disability without treatment.

Biologics (Biological Response Modifiers)

If DMARDs like methotrexate don't help stop rheumatoid arthritis, biologics are the next course of action, says Hadler.

Biologics are a more aggressive, targeted therapy that can actually significantly slow progression of rheumatoid arthritis within a few weeks -- rather than just treating the symptoms. However, biologics can cause flare-ups of other chronic diseases that are in remission, particularly infections like tuberculosis. Biologics may also cause an increased risk of cancer.

"It's something we have to consider," says White. As always, White asks her patients to weigh the risks and benefits given the stage and severity of their rheumatoid arthritis.

Hadler calls biologics "impressive drugs," but usually waits a few months before prescribing them, and is wary about prescribing them for patients in their 20s, 30s, 40s.

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"We have had the drugs for a decade, so we know about toxicities for that time frame," Hadler tells WebMD. "But we don't know what these drugs will do if you're taking them for longer than 10 years or for five years and stop for awhile."

He notes that only a third of people with rheumatoid arthritis need aggressive treatment. He says he turns to biologics only for patients who have progressive rheumatoid arthritis. "If we treat them all aggressively, how will we know if they really need these serious drugs -- and for how long?"

Published May 2007.

WebMD Feature Reviewed by Louise Chang, MD on May 18, 2007

Sources

SOURCES: Patience White, MD, chief public health officer for the Arthritis Foundation. Nortin Hadler, MD, a rheumatologist and professor of medicine at the University of North Carolina at Chapel Hill. WebMD Medical Reference in collaboration with The Cleveland Clinic: "Anti-Inflammatory Painkiller Drugs and Arthritis," "Steroids to Treat Arthritis," "Narcotic Pain Medication," "Treating Rheumatoid Arthritis with Disease-Modifying Drugs (DMARDs)." WebMD Medical Reference: "Pain Relief for Rheumatoid Arthritis" and "Biologics for Rheumatoid Arthritis Treatment." WebMD Medical News: "Ibuprofen Risky for Heart Patients?" and "Arthritis Drugs May Up Cancer Risk." WebMD Medical Reference from Medicinenet.com: "Osteoarthritis Treatments: Know Your Options."

© 2007 WebMD, Inc. All rights reserved.

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