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Choosing Pain Medicine For Osteoarthritis

Consumer Summary Guide published 10 Jan 2007

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1. Introduction

What does this guide cover?

This guide can help you work with your doctor or nurse to choose pain-relief medicine for osteoarthritis.

  • It describes the different kinds of pain relievers.
  • It also gives information about the trade-offs between pain relief, risks of problems, and the price of the medications.

This guide is based on a government-funded review of the research about pain-relief medicines for osteoarthritis. It includes over-the-counter (OTC) medications and some prescription (Rx) drugs.

Each of the medicines in this guide comes with benefits and risks.

  • On the up side, they reduce pain and swelling. They can also help you stay active.
  • On the down side, they may cause stomach bleeding or raise your chance for a heart attack.

People are different in how they weigh benefits and risks. Some people feel that a small increased chance of heart attack would be okay if they could get the pain relief they need. Other people would not want this kind of trade-off.

This guide can help you learn about the benefits and risks of pain-relief medicines for osteoarthritis. Knowing about the benefits and risks can help you decide what is right for you.

What is not covered?

This guide does not include all the ways to reduce osteoarthritis pain. Exercise, losing weight, acupuncture, and surgery are some other ways to help you feel better and stay active. It also does not cover Rx opiate medications like morphine, Tylenol-3®, and Vicodin®.

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2. Fast Facts

Fast Facts on Pain Relievers
  • Acetaminophen (Tylenol®) works on mild pain and has fewer risks than other pain pills.
  • Prescription (Rx) pain pills may work better than over-the-counter (OTC) pain pills. They also have a higher chance of serious problems like stomach bleeding and heart attacks.
  • NSAID pills, like ibuprofen (Motrin®, Advil®), naproxen (Aleve®) or aspirin, reduce pain but can cause stomach bleeding. You can lower your risk by taking the lowest dose you can for the shortest time you can.
  • Aspirin can cause stomach bleeding even at low doses.
  • Capsaicin skin cream, like Theragen® or Zostrix®, can help with mild pain. Capsaicin cream also has fewer risks than pain pills.
  • Salicylate skin cream, like Aspercreme® or Bengay Arthritis®, does not work for osteoarthritis pain.

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3. Understanding the Benefits of Pain Medicines

Over-the-counter (OTC) pain relievers

Acetaminophen (Tylenol®)

  • Most people can take acetaminophen (Tylenol®) without problems as long as they follow the directions on the bottle.
  • Research shows that acetaminophen (Tylenol®) reduces mild pain. It probably does not help with inflammation or swelling.

OTC NSAIDs

  • Non-steroidal anti-inflammatory drugs are called NSAIDs (pronounced "EN-seds"). They include aspirin, ibuprofen (Advil®, Motrin®), and naproxen (Aleve®). These pills work by blocking pain enzymes.
  • Research shows that NSAIDs reduce pain caused by swelling. They also give general pain relief.
  • Aspirin is also an NSAID, but there is not much research about using aspirin for osteoarthritis pain.

Glucosamine and chondroitin

  • Glucosamine and chondroitin are supplements. They are not regulated as drugs in the United States, so their quality may vary. There is no way to be sure that the supplements you get in the store are as good as the ones used in the research studies.
  • Research shows that the combination of glucosamine hydrochloride plus chondroitin sulfate may reduce moderate to severe pain without causing serious problems.

Skin creams

  • Capsaicin (pronounced "cap-SAY-sin") cream, like Zostrix® or Theragen®, is made from chili peppers. Research shows that it reduces mild pain.Five out of 10 people using it will have warm, stinging, or burning feelings. The burning feelings fade away over time.
  • Salicylate (pronounced "sa-LI-si-late") cream includes Aspercreme® and Bengay Arthritis®. Research shows that salicylate cream does not work for osteoarthritis pain.

Prescription (Rx) pain-relief pills

Rx pain pills include prescription-strength NSAIDs and opiates (morphine, Tylenol-3®, Vicodin®). This guide does not cover opiates. There are three kinds of Rx NSAID pills:

 

Traditional Rx NSAID pills

  • These are Rx pills like ibuprofen (Motrin®), diclofenac (Voltaren®), and indomethacin (Indocin®).
  • Rx NSAID pills are stronger and often cost more than OTC NSAIDs.
  • Research shows that they relieve pain and swelling.

COX-2 inhibitors

  • Celecoxib (Celebrex®) is a kind of NSAID called a COX-2 inhibitor. It relieves pain as well as other NSAIDs do.
  • Short-term research studies found that celecoxib (Celebrex®) is safer on the stomach than other NSAID pills.
  • Two other COX-2 inhibitors (Vioxx® and Bextra®) were taken off the market in 2005 because they have a high risk of causing heart attacks.

Salicylates

  • Salicylates, pronounced "sa-LI-si-lates", are Rx NSAID pills like salsalate, pronounced "SAL-sa-late" (Disalcid®).
  • We do not know how salicylates compare to other osteoarthritis pain relievers because there is very little research.

Warning - If you have ever had stomach bleeding, high blood pressure, heart attack, liver or kidney problems, you have higher risk for serious problems. Talk to your doctor or nurse before taking any pain pills.

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4. Understanding the Risk of Problems

What is the risk of stomach bleeding with NSAID pills?

All NSAID pills, including aspirin, block enzymes that protect the stomach. This can cause stomach bleeding. It is not possible to predict any one person's risk. Research can't tell how long you can use NSAID pills without bleeding. In general, stomach bleeding is more likely for people taking NSAIDs who:

  • Are older, especially more than 75 years old.
  • Take higher doses.
  • Use NSAIDs for a longer time.
  • Also take medicine to help prevent blood clots, like aspirin or warfarin (Coumadin®).
Older people taking NSAID pills have higher risk of stomach bleeding
  • For people age 16-44:
    •    5 out of 10,000 people taking NSAIDs will have a serious bleed
    •    1 out of 10,000 people taking NSAIDs will die from a bleed
  • For people age 45-64:
    • 15 out of 10,000 people taking NSAIDs will have a serious bleed
    •   2 out of 10,000 people taking NSAIDs will die from a bleed
  • For people age 65-74:
    • 17 out of 10,000 people taking NSAIDs will have a serious bleed
    •   3 out of 10,000 people taking NSAIDs will die from a bleed
  • For people age 75 or older:
    • 91 out of 10,000 people taking NSAIDs will have a serious bleed
    • 15 out of 10,000 people taking NSAIDs will die from a bleed
What are the signs of stomach bleeding?

Call your doctor or nurse right away if you:

  • Vomit blood.
  • See blood in your bowel movement, or your bowel movement is black and sticky like tar.
  • Feel very weak.
What if I had stomach bleeding in the past?

If you have ever had stomach bleeding, do not take any of the NSAID pills, including aspirin. If your doctor or nurse recommends NSAID pills, be sure to tell him or her that you had stomach bleeding in the past.

What about the risk of heart attack?

NSAIDs can increase the chance of a heart attack. For every 10,000 people taking NSAIDs, 30 of them will have a heart attack that they would not have had if they were not taking NSAIDs. Recent research found that:

  • Some NSAIDs increase the chance of a heart attack:
    • Celecoxib (Celebrex®).
    • Ibuprofen (Motrin®) in high doses (800 mg three times a day).
    • Diclofenac (Voltaren®) in high doses (75 mg twice a day).
  • Naproxen (Aleve®, Naprosyn®) does not increase the chance of a heart attack.
  • We do not know how other NSAIDs compare when it comes to the chance of a heart attack.
What about risk to the liver?

Liver problems are rare with acetaminophen (Tylenol®) and the other pain pills described in this guide. However, taking too much acetaminophen (Tylenol®) can lead to liver problems. Be sure to follow the directions on the bottle. Keep in mind that other medicines contain acetaminophen (Tylenol®). Be sure to check the labels so that you do not take too much.

What about risk to the kidneys?

The risk is low, but all NSAID pills and acetaminophen (Tylenol®) can cause or worsen high blood pressure and kidney problems. Two out of 1000 people stop their medicine because of kidney problems.

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5. Sorting it Out

1. Benefit

The first step in choosing pain medicine is to sort out what kind of pain relief you need.

Do you want to be more active?

Pain-relief medicine can help you keep moving. Start low. Use lower strength and lower dose pills for mild pain. Try capsaicin skin cream (Theragen®, Zostrix®) or acetaminophen (Tylenol®), because they have fewer risks than other pain relievers.

Do you want to reduce swelling or inflammation?

Try NSAID pills such as naproxen (Aleve®) or ibuprofen (Advil®, Motrin®). You can lower your risk of problems by using the lowest dose you can for the shortest time you can.

2. Risk

The second step is to know your risks for problems, like stomach bleeding and heart problems.

Have you ever had stomach bleeding or were told you are at high risk for bleeding?

Do not use NSAID pills, including aspirin, unless they are recommended by your doctor or nurse. The best way to avoid stomach bleeding is to use acetaminophen (Tylenol®) as your pain pill, or use capsaicin skin cream (Zostrix®, Theragen®).

Have you ever had a heart attack or were told you are at high risk for one?

Most people can take acetaminophen (Tylenol®), aspirin, or naproxen (Aleve®, Naprosyn®). There is a chance of heart problems with other pain relief pills, so talk to your doctor or nurse before trying them.

Do you take low-dose aspirin?

Aspirin, even at low doses, can cause stomach bleeding. If you want to take low-dose aspirin, consider a pain reliever that is not an NSAID pill, like capsaicin skin cream (Theragen®, Zostrix®), acetaminophen (Tylenol®), or glucosamine and chondroitin.

Warning - Combining aspirin and other NSAID pills makes bleeding more likely.

3. Cost

The third step is to find out about the cost.

Is cost an issue for you?

Use the following charts to compare the prices of different drugs. If Rx drugs are included in your health insurance plan, check with your plan about the cost to you.

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6. Price

OTC Pain Relievers*
Drug Name Brand Names Strength** Price for 100 Pills or
1 Tube***
  Generic Brand
Acetaminophen Tylenol®  325 mg
 500 mg 		$2
$3 		$7
$8
Oral NSAIDs
Aspirin Bayer®, Ecotrin®  325 mg
 325 mg EC 		$2
$2 		NA
$5
Ibuprofen Advil®, Motrin®  200 mg $4 $10
Naproxen Aleve®  220 mg $7 $8
Topical Creams
Capsaicin Theragen®, Zostrix®    60 gm tube (.025%)
   60 gm tube (.075%) 		$8
NA 		$12
$17
Supplements
Glucosamine hydrochloride plus chondroitin sulfate    500mg/400mg three times a day $55 NA

* This chart includes pain relievers from the research studies. OTC brand names are just a few examples of those sold in 2005.
** EC = enteric coated (helps prevent stomach damage).
*** Average Wholesale Price from Drug Topics Redbook, 2006.
NA = Not available.

Prescription NSAID Pain Relievers*
Drug Name Brand Names Dose** Price for 1-Month Supply***
  Generic Brand
Traditional NSAIDS
Diclofenac Voltaren®, Catalam®    75 mg twice a day
   50 mg three times a day
 100 mg XR once a day 		$70
$85
$85 		$160
$175
$160
Etodolac Lodine®  400 mg twice a day
 400 mg three times a day 		$90
$130 		$110
$170
Ibuprofen Motrin®  400 mg three times a day
 800 mg three times a day 		$20
$35 		$30
$45
Indomethacin Indocin®    50 mg three times a day
   75 mg SR twice a day 		$65
$130 		NA
$140
Ketoprofen Oruvail®    75 mg three times a day
 200 mg ER once a day 		$95
$85 		$115
$100
Meloxicam Mobic®     7.5 mg once a day
   15 mg once a day 		NA
NA 		$100
$155
Nabumetone Relafen® 1000 mg once a day
1500 mg once a day 		$85
$100 		$125
$150
Naproxen Anaprox®, Naprelan®, Naprosyn®  250 mg three times a day
 500 mg twice a day
 500 mg three times a day 		$70
$80
$120 		$105
$110
$165
Piroxicam Feldene®    20 mg once a day $75 $115
COX-2 Inhibitor
Celecoxib Celebrex®  100 mg twice a day
 200 mg twice a day
 400 mg twice a day 		NA
NA
NA 		$125
$200
$300
Salicylates
Salsalate Disalcid®, Salflex®  750 mg twice a day $20 $30

* This chart includes pain relievers from the research studies.
** XR/ER = extended release, SR = sustained release.
*** Average Wholesale Price from Drug Topics Redbook, 2006.
NA = Not available.

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The information in this guide comes from a detailed review of 351 research reports called Comparative Effectiveness and Safety of Analgesics for Osteoarthritis (2006), and was written by the Oregon Evidence-based Practice Center.

The Agency for Healthcare Research and Quality (AHRQ) created the Eisenberg Center at the Oregon Health & Science University to make research helpful for consumers. This guide was prepared by Sandra Robinson, M.S.P.H., Roger Chou, M.D., Theresa Bianco, Pharm.D., Martha Schechtel, R.N., and David Hickam, M.D., of the Eisenberg Center. People with osteoarthritis helped them write this guide.

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8. For More Information

Visit the clinician guide Choosing Non-Opioid Analgesics for Osteoarthritis.

For free print copies call:

The AHRQ Publications Clearinghouse
(800) 358-9295

Ask for AHRQ Publication Number:
06(07)-EHC009-2A

For more information about osteoarthritis, visit the MedlinePlus Web site:
www.nlm.nih.gov/medlineplus/osteoarthritis.html

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