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The term arthritis is used to describe a variety of rheumatic diseases that result in inflammation of the joints. While stiffness, limited range of motion, and swelling all are common symptoms of arthritis, the hallmark feature of most arthritides is pain in the joints. In some people this pain can be mild and only minimally interferes with daily life. In others, the pain can be debilitating and can significantly restrict activity and lifestyle. Osteoarthritis, rheumatoid arthritis, and gout are among the most common forms of arthritis. There are many aspects to treatment of these arthritic diseases, including medications to slow the progress or modify the course of the disease. Medication for pain relief is also an integral part of disease management. While some analgesics are used as pain relievers in all three diseases, others have been demonstrated to be effective only against a particular disease.
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Acetaminophen (also known as paracetamol or APAP or by trade names such as Tylenol) is a drug that has been used for decades to control pain in arthritis. Despite this, its precise mechanism of action is still poorly understood. One theory is that it acts on one site of the cyclooxygenase enzyme responsible for producing pain and inflammation-inducing symptoms. Called the “peroxidase site,” it’s different from the one that nonsteroidal anti-inflammatory drugs (NSAIDs) act upon.
A disadvantage to acetaminophen is that it can have severe liver toxicity at high doses. Many over-the-counter medications ranging from cold medicines to headache remedies contain acetaminophen, increasing the risk that someone might overdose if they take these in addition to a single source of acetaminophen (such as Tylenol).
- Osteoarthritis: The American College of Rheumatology (ACR) recommends acetaminophen for pain control of hip and knee OA.
- Rheumatoid arthritis: The ACR considers acetaminophen a pain control option for RA.
- Gout: There are no ACR recommendations for acetaminophen use in gout pain control.
Over-the-counter NSAIDs such as ibuprofen and naproxen and and prescription NSAIDs such as fenoprofen and meloxicam work by acting on the cyclooxygenase enzymes, reducing the production of pain and inflammation-producing prostaglandins. Over-the-counter NSAIDs and lower doses of most NSAIDs tend to provide pain relief while higher doses and prescription NSAIDs provide pain relief and a more significant anti-inflammatory effect.
The use of NSAIDs can be limited by the increased risk of gastrointestinal (GI) bleeding and the increased risk of heart attack and stroke that is associated with them. These risks are present even with short-term use but increase the longer they are taken.
A subclass of NSAIDs called cycolooxygenase-2 inhibitors or COX-2 inhibitors (such as celecoxib) act selectively on the cyclooxygenase-2 enzyme; the result is fewer GI side effects, but COX-2 inhibitors are still associated with an increased risk of cardiovascular disease. It’s important to work with your healthcare provider to determine the appropriate NSAIDs dose and length of use given these risks.
- Osteoarthritis: The ACR recommends oral and topical NSAIDs for OA of the hand, knee, and hip in people under the age of 75. For people 75 and older, topical NSAIDs are recommended over oral NSAIDs because of GI bleeding risks.
- Rheumatoid arthritis: The ACR recommends oral NSAIDs as a pain relief option for RA.
- Gout: The ACR recommends NSAIDs for the treatment of acute gout pain. They do not have recommendations on the use of topical NSAIDs.
Opioids are a class of prescription drugs that provide pain relief by interfering with the transmission of pain signals and stimuli from peripheral nerves to the brain. Opioids are often divided into what are called “weak” opioids (such as codeine and hydrocodone) and “strong” opioids (such as oxycodone and morphine).
While opioids do not have an anti-inflammatory effect, they can be potent pain relievers; however, they have negative side effects including nausea, constipation, somnolence, and a significant risk for addiction.
- Osteoarthritis: The ACR recommends use of opioids for OA only in people who had inadequate response to other therapies or who failed other medical therapy and were not candidates for joint replacement.
- Rheumatoid arthritis: A large meta-analysis of studies evaluating the use of opioids for RA pain relief suggests that weak opioids used for no longer than 6 weeks may provide effective pain relief for people suffering from RA but should be judiciously monitored by healthcare providers.
- Gout: There are no official recommendations and for opioids in treating gout pain, although some healthcare providers may prescribe them.
Often called an atypical opioid drug because it acts by some of the same mechanisms as traditional “weak” opioids, tramadol also has different analgesic mechanisms of action involving the neurotransmitters serotonin and norepinephrine.
Side effects of tramadol are similar to those of traditional “weak” opioids but are less intense owing to its lower true opioid content. Patients may also experience symptoms such as flushing related to the neurotransmitter effect.
- Osteoarthritis:The ACR recommends tramadol as a pain relief option for people with OA of the hand, hip, and knee.
- Rheumatoid arthritis: While there are no specific recommendations regarding tramadol, large meta-analyses of studies of tramadol in people with RA found the results were the same as with other “weak” opioids.
- Gout: There are no recommendations for tramadol in gout pain management.
Despite the fact that colchicine has been used as a treatment for gout for more than 2,000 years, scientists still don’t understand its exact mechanism of action. Colchicine is derived from a plant known as the autumn crocus, or “meadow saffron,” and is thought to work by reducing the inflammatory response to uric acid crystals in affected joints and thereby reducing pain. At higher doses it can cause significant side effects of nausea, vomiting, and diarrhea and therefore is best tolerated at lower doses.
- Osteoarthritis: Not recommended.
- Rheumatoid arthritis: Not recommended.
- Gout: Oral colchicine is recommended for pain control in acute gout if initiated within 36 hours of the onset of symptoms. It may be used short-term to prevent acute gout attacks in people beginning uric acid-lowering medications that can occasionally precipitate an acute gout attack.
Steroids reduce the immune system’s inflammatory response through a variety of mechanisms, including decreased release of pro-inflammatory chemicals such as prostaglandins and decreased migration of inflammatory white blood cells to sites of inflammation. Options include oral steroids such as prednisone or cortisone; injectable steroids such as betamethisone or triamcinolone; and topical steroids such as diclofenac.
The pain relief associated with steroids is not a direct effect, but rather a consequence of the reduction in inflammation-associated pain such as swelling. Oral steroids are not recommended for long-term use because they can have significant side effects, including osteoporosis and increased risk of bone fracture, immunosuppression, hypertension, increased risk of diabetes or worsening of pre-existing diabetes, glaucoma, and weight gain, among others. Intraarticular steroids if administered too frequently, can cause destruction of cartilage and therefore must be used judiciously.
- Osteoarthritis: Intraarticular steroid injections are recommended in people with OA of the hip and knee.
- Rheumatoid arthritis: The ACR recommends low-dose steroid use in patients with early RA as an adjuvant to disease-modifying therapy (such as disease-modifying anti-rheumatic drugs or DMARDs or biologics) and in patients with established RA who are not responding to disease-modifying therapy or experiencing a flare on such therapy.
- Gout: The ACR recommends short-term oral or an intraarticular steroid injection for acute gout when one or two joints are involved. For acute gout involving more than two joints, short-term oral steroids are recommended.
Capsaicin is a compound derived from chili peppers that when used topically has been shown to reduce levels of chemical in the body called substance P. Substance P is a neurotransmitter involved in the transmission of pain signals.
- Osteoarthritis: The American College of Rheumatology recommends the use of topical capsaicin for OA of the hand.
- Rheumatoid arthritis: Topical capsaicin is considered a pain relief option by the American College of Rheumatoid Arthritis Pain Management Task Force; however, it is primarily used in combination with other treatments.
- Gout: Capsaicin is not used for management of gout pain unless the gout has caused permanent joint damage.
Originally published in May 2016 and updated.