Drug Therapies

Because there is no cure for osteoarthritis, most current treatments aim to relieve symptoms. Pain relief and improved physical function are the primary targets. OA is a complex condition with many variables, so there is no real consistency from patient to patient regarding the effectiveness of drug therapies commonly used to treat the condition. Side effects can be significant and often debilitating. Fatigue, drowsiness, nausea, weight fluctuations and difficulty breathing cause some patients to limit or stop use of a drug. This is especially true among people who have OA with additional chronic conditions (comorbidities). In addition, many people with OA who face treatment decisions have concerns about the long-term effects of drug therapies but often lack clear and comprehensive information to help them make these difficult decisions.

NSAIDs & Analgesics

For relief of pain associated with osteoarthritis, analgesics such as acetaminophen are often used. However, these drugs do not help with inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to control both pain and inflammation in people with OA. There are more than 100 different NSAIDs, available by prescription and over-the-counter in the form of pills, liquids, patches and topical gels. Because the effectiveness of these drugs varies from person-to-person, finding the one that works most effectively often is a process of trial and error.

Many people with OA experience side effects when taking NSAIDs, including gastrointestinal distress and bleeding. Even more concerning, in patients with existing heart disease or risk factors like hypertension and obesity, taking NSAIDs increases the risks of heart attack and stroke significantly. Taking higher doses for longer periods of time increases risks even more.

Opioids

Although opioids can be used to treat the pain associated with osteoarthritis, there is a general consensus that the potential harmful effects far outweigh the benefits. A review of studies of patients with OA using opioids for pain showed that strong opioids were not more effective than NSAIDs. There is also a high risk of death due to misuse and abuse. (OARSI p. 43)

The EPIC task force states that due to the high risk of abuse and lack of clinical benefit over other treatment options, use of opioids for OA pain management is not recommended. If opioids are prescribed due to an acute flareup, it should be as a last resort and in combination with non-drug therapies. In addition, CDC guidelines should be followed to include development of a treatment plan that details a strategy for discontinuing the drug to be shared with the entire health care team. (EPIC p. 17)

Review the MBGH Toolkit Addressing Pain Management & Opioid Use/Abuse: Prescribing Trends for Pain Management for more information on this topic.

Intra-Articular (IA) Injections

When pain and inflammation experienced as a result of osteoarthritis do not respond to first-line, conservative treatments like NSAIDs, analgesics or physical therapy, intra-articular injections may be prescribed. These injections, most frequently used for knee OA, are delivered directly into the joint. The length of time a patient feels relief varies and the benefits decrease over time.

The FDA has approved two different IA injections:

• Hyaluronic acid (HA) injections provide lubrication and cushioning, replacing a naturally occurring joint fluid that breaks down in people with OA. This option seems to work best in people with mild to moderate osteoarthritis and is often used when steroids or other medications cannot be tolerated. Benefits from HA injections can last up to six months and are sometimes used to delay knee replacement surgery.
• Corticosteroids have strong anti-inflammatory properties and have been used for years to help reduce pain and inflammation. Some trials have shown a moderate improvement in pain and small increase in function following a cortisone injection, however benefits are greatly reduced after three months. There is some concern that using this type of injection may cause cartilage to deteriorate. 

Emerging Treatments

There is a significant need for new and innovative therapies that focus on improving quality of life and/or stopping progression of the disease. This is an area worthy of watching. Two additional types of injections not yet FDA approved are Platelet-Rich Plasma Injections (PRP) and Stem Cell Injections.