Medications:

Acetaminophen

Acetaminophen (Tylenol) is the first choice for treating osteoarthritis. (Acetaminophen may be less effective than NSAIDs in reducing moderate-to-severe pain.) Because acetaminophen has fewer side effects, most doctors suggest trying this drug first, then switching to an NSAID if acetaminophen does not provide sufficient pain relief.

Side Effects. Acetaminophen is inexpensive and generally safe. It poses far less of a risk for gastrointestinal problems than NSAIDs.

It does have some adverse effects, however, and the daily dose should not exceed 4 grams (4,000 mg). Patients who take high doses of this drug for long periods are at risk for liver damage, particularly if they drink alcohol and do not eat regularly.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. There are dozens of NSAIDs available:

• Over-the-counter NSAIDs NSAIDs include aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), ketoprofen (Actron, Orudis KT).
• Prescription NSAIDs include flurbiprofen (Ansaid), diclofenac (Voltaren, Cataflam), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), nabumetone (Relafen), dexibuprofen (Seractil), indomethacin (Indocin), meloxicam (Mobic, generic).
• Topical NSAIDs are gels, creams, or patches that are available either by prescription or over-the-counter. It is not clear how effective they are for osteoarthritis.

Oral NSAIDs should be used only for a short period of time. Long-term use of NSAIDs does not actually delay the progression of osteoarthritis and can increase patients' risk of side effects.

Patients should use only the lowest effective dose because high dosages of NSAIDs can cause heart problems (such as increased blood pressure and risk of heart attack), kidney problems, and stomach bleeding. Patients who are at increased risk of stomach bleeding and ulcers should either switch to another type of pain reliever, or take the NSAID along with a proton-pump inhibitor drug, such as omeprazole (Prilosec) or esomeprazole (Nexium), or with misoprostol (Cytotec). (Misoprostol can cause miscarriage and should not be used by women who may be pregnant.)

COX-2 Inhibitors (Coxibs)

Coxibs inhibit an inflammation-promoting enzyme called COX-2. This drug class was initially thought to provide benefits equal to NSAIDs but cause less gastrointestinal distress. However, following numerous reports of cardiovascular events, as well as skin rashes and other adverse effects, most COX-2 inhibitors were withdrawn from the market. Celecoxib (Celebrex) is still available, but patients should discuss with their doctors whether this drug is appropriate and safe for them.

Capsaicin

Capsaicin is a component of hot red peppers and may bring pain relief when used as a skin cream (Zostrix). This is the only skin preparation that does more than just mask pain or reduce it temporarily. Capsaicin seems to reduce a substance in the body, known as substance P, which contributes both to inflammation and the delivery of pain impulses from the central nervous system. A small amount of capsaicin must be applied to the area of inflammation about four times a day. During the first few days of use, the patient will experience a warm, stinging sensation when the cream is applied. This sensation goes away, and pain relief usually begins within 1 - 2 weeks.

Tramadol

Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea but does not cause severe gastrointestinal problems, as NSAIDs can. Some patients experience severe itching. A combination of tramadol and acetaminophen (Ultracet) is available.

Narcotics

Narcotics, pain-relieving and sleep-inducing drugs that act on the central nervous system, are the most powerful medications available for the management of moderate-to-severe pain. There are two types of narcotics:

• Opiates, which are derived from natural opium (morphine and codeine)
• Opioids, which are synthetic drugs. They include oxycodone (such as Percodan, Percocet, Roxicodone, and OxyContin), hydrocodone (Vicodin), oxymorphone (Numorphan), and fentanyl (Duragesic)

Although the use of narcotics for arthritic pain is controversial, they may have a place in osteoarthritis treatment when milder drugs are not effective or appropriate. These drugs can be highly addictive, and should be prescribed at the lowest possible effective dose.

Common side effects include anxiety, constipation, nausea and vomiting, dizziness, drowsiness, paranoia, urinary retention, restlessness, and labored or slow breathing.

Corticosteroid Injections

When pain becomes a major problem and less potent pain relievers are ineffective, doctors may try corticosteroid (steroid) injections, usually by giving the patient a shot in their joint every 3 months. Corticosteroid shots are useful only if inflammation is present in the joint. Relief from pain and inflammation is of short duration, and this treatment is rarely used for chronic osteoarthritis. These drugs may not be as effective for women as they are for men.

Patients are usually advised not to have more than two or three injections a year, since there is some concern that repeated injections over the long term may be harmful. Because long-term use of corticosteroids has many potentially serious side effects, steroid medications are never given by mouth or systemically for the treatment of osteoarthritis.

Hyaluronic Acid Injections (Viscosupplementation)

Injections of hyaluronic acid (such as Hyalgan, Synvisc, Artzal, and Nuflexxa) into the joint -- a procedure called viscosupplementation -- may provide pain relief for knee osteoarthritis. Relief usually lasts several months. The most common side effects, pain at the injection site and knee pain and swelling, are usually mild and temporary.