Features October 2003 Issue

Pain: What Meds Do You Grab First?

It depends on whether you have OA or RA—and the severity of your pain.

Joint pain is one of the early symptoms of osteoarthritis (OA) and rheumatoid arthritis (RA). Because the pain can become so debilitating, patients typically ask their doctor: “Is there anything I can take that will make the pain go away?” The answer is “yes,” but what pain reliever you should take depends on whether you suffer from OA or RA, and how persistent and severe your pain happens to be.

Safest drugs first
Dr. Daniel Mazanec, a rheumatologist and director of the Spine Center at The Cleveland Clinic, says: “Fortunately, there are several analgesics to choose from. We start with the safest ones that are likely to be effective because we don’t want to take unnecessary risks.” An important consideration is what type of arthritis you have—OA or RA. For patients with OA, the first analgesic of choice is acetaminophen, commonly known in the U.S. by the brand name Tylenol. If you suffer from RA, the first choice is one of the many available non-prescription non-steroidal anti-inflammatory drugs (NSAIDs)—medications like aspirin, ibuprofen (Motrin, Nuprin), and naproxen (Aleve, Naprelan).

Isn’t all joint pain the same?
“There’s a difference in what causes pain in OA and RA, and that’s called inflammation,” says Dr. Mazanec. “Inflam-mation also causes the other common symptoms of RA: morning stiffness, redness, swelling, and occasional low-grade fevers. These symptoms are not usually seen in patients with OA.” In contrast, OA is a degenerative disease, with inflammation becoming a factor as more of the joint cartilage becomes eroded. With RA, you can treat the inflammation to provide pain relief, but with OA you first treat the perception of pain, which occurs mainly in the brain—and new evidence suggests that the brain is where acetaminophen acts.

When pain gets worse
Unfortunately, both OA and RA are progressive diseases—which means that, as time goes on, pain is likely to be worse and occur more often. As each disease progresses, most patients find that the analgesics they once took no longer work. “We call this ‘breakthrough’ pain, and it means we need to adjust the drugs you take to restore effective pain relief,” says Dr. Mazanec. Again, the options are different for OA and RA.

Breakthrough pain in OA is treated with more acetaminophen, but this is effective only to a point. And then things get dangerous. Taking more than four grams of acetaminophen a day (about eight Extra Strength Tylenol capsules) increases the risk of liver toxicity. Your physician will then recommend that you either switch to a different non-prescription NSAID, either instead of or along with acetaminophen, to see if the change in regimen helps. If it doesn’t, your doctor may recommend you take a NSAID available by prescription, such as diclofenac (Arthrotec, Voltaren), celecoxib (Celebrex), or rofecoxib (Vioxx). If that combination doesn’t work, an opioid analgesic, such as tramadol (Ultram), probably will be prescribed.

If you suffer from RA, more effective anti-inflammatory drugs are the best choice. You likely will try NSAIDs available by prescription first. If that doesn’t work, glucocorticoids and disease-modifying antirheumatic drugs (DMARDs) may be recommended. Glucocorticoids and DMARDs are not analgesics, but they are usually effective in reducing inflammation, the fundamental cause of pain in RA.

Ultimately, the choice of analgesic is made on the basis of safety, how well it works, and cost. Acetaminophen is the safest and one of the least expensive drugs. Most NSAIDs are associated with an increased risk of stomach bleeding and ulcer formation, and those available over the counter are inexpensive. “Coxibs”—celecoxib and rofecoxib—are NSAIDs that eliminate much of the risk of side effects concerning the stomach, but they are available by prescription only. Opioids are effective pain relievers but are associated with physical dependence with long-term use. True addictive behavior is rare, but constipation and sedation are common side effects.

Glucocorticoids and DMARDs are associated with a variety of serious side effects, including hypertension, osteoporosis, and increased risk of infection. “As physicians,” says Dr. Mazanec, “we must always balance the severity of pain and other symptoms of OA and RA and the effect they have on our patients’ lives with the risk of adverse side effects of the drugs we recommend. Most patients are willing to take on additional risk if there’s a good chance it will improve their condition and quality of life.”