comparisonofarthritisdrugs

A Comparison of Drugs for Osteoarthritis

People with osteoarthritis are often in chronic pain and that usually means long-term use of non-steroidal anti-inflammatory drugs, or NSAIDs*. To help them weigh the risks and benefits of these drugs, the U.S. Agency for Healthcare Research and Quality has issued a report on its Web site. It concluded that all NSAIDs—both over-the-counter and prescription—“present similar, increased risks of heart attacks while offering about the same level of pain relief.” There is, however, a notable exception: Naproxen (Aleve, Naprosyn) does not increase the chance of a heart attack. Conversely, Celebrex is associated with a higher risk of heart attack than the other NSAIDs.

The report drew upon the best research findings for both prescription and non-prescription NSAIDs, but did not include information about prescription opiate medications like morphine, Tylenol-3, and Vicodin.

*All the oral drugs mentioned in this article are NSAIDs. The exception is acetaminophen (Tylenol) which is a pain reliever with no anti-inflammatory effects.

Here are the highlights:

Mild Pain:

-Acetaminophen (Tylenol) works on mild pain and has fewer risks than other pain pills.

-There were mixed results for topical drugs. Capsaicin skin cream, like Theragen or Zostrix, can help with mild pain, but half the people using this product, which has fewer risks than NSAIDs, experience a burning sensation that diminishes over time. Salicylate skin cream, such as Aspercreme and Bengay Arthritis, does not work for osteoarthritis pain.

Moderate to Severe Pain:

-The popular dietary supplements glucosamine hydrochloride (1500 mg a day) plus chondroitin sulfate (1200 mg a day) can reduce moderate to severe pain without serious side effects, but this combination has no effect on mild pain. Keep in mind, though, that the FDA does not regulate these or any other supplements, so the quality will vary.

-Celebrex relieves pain just as well as the other NSAIDs, but this drug also comes with a higher risk of heart attacks. All NSAIDs, like ibuprofen (Motrin, Advil), naproxen (Aleve) or aspirin, will reduce pain but can also cause stomach bleeding. Lower your risk by taking the lowest dose for the shortest time possible. But even at low doses, aspirin can cause stomach bleeding.

High Doses

-Ibuprofen (Motrin) in high doses (800 mg three times a day) and diclofenac (Voltaren) in high doses (75 mg twice a day), respectively, can increase the risk of heart attack. For other oral NSAIDs, there are no comparative studies regarding heart risks to make reliable judgments.

-Naproxen, even at high doses (500 mg twice a day), does not increase the risk of heart attack.

The Most Common Serious Risk

All NSAIDs, including aspirin, block enzymes that protect the stomach. This can cause stomach bleeding.

There are no studies to help you determine how long you can take NSAIDs without bleeding. Generally speaking, 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; or also take medicine to help prevent blood clots, like aspirin or warfarin (Coumadin).

Celebrex has a lower risk of bleeding than other NSAIDs only if taken short term (unfortunately this report does not define short term). However, adding daily aspirin therapy (even at a low dose) to chronic use of Celebrex will either reduce or negate any protective benefit.

Risk of Stomach Bleeding Rises with Age

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

For More Information

Go to Agency for Healthcare Research and Quality (http://effectivehealthcare.ahrq.gov/reports). Scroll down to “Muscle, Bone and Joint Conditions” and click into “Choosing Pain Medicine for Osteoarthritis”. The physicians’ version of the same report is also available. Both have an excellent section listing the comparative prices of a one-month supply of brand and generic versions of all the drugs mentioned in the report. For free print copies call (800) 358-9295 and ask for AHRQ Publication Number:
06(07)-EHC009-2A.

, and colleagues at two European medical centers. They found nine trials had produced enough information to pool results and come to a conclusion about the effectiveness of acupuncture for arthritic knee pain.

All nine trials had some sort of comparison group against which the effects of acupuncture could be measured. The comparator was either a sham procedure (i.e., needles placed away from the traditional points), or usual care (e.g., anti-inflammatory drugs), or time spent on a waiting list for acupuncture treatment. All trials had randomly assigned participants to receive one of these treatments or acupuncture for at least six weeks. Randomly assigned means that the participants cannot choose their treatment.

Acupuncture showed moderate to large benefits in the trials that compared it with usual care or waiting list, and small benefits in the trials that compared it with a sham procedure. Significantly, acupuncture showed little to no benefit in the two trials that compared it with a sham acupuncture procedure that was clearly indistinguishable to the participants from the true acupuncture.

The analysis of all nine trials suggested that the more likely participants knew or suspected they were getting real acupuncture, the more likely they were to report a benefit. This led Manheimer and colleagues to conclude that placebo effects are mostly responsible for the benefits of acupuncture.

In a telephone interview, Eric Manheimer mentioned the importance of trials that not only had sham acupuncture as a comparator but had also tested the credibility of the sham procedure. This means that after the trial is over, the investigators asked the participants if they knew whether were getting the real or the sham acupuncture, explained Manheimer, and the participants could not distinguish between the two procedures.

But things are even more complicated because the sham acupuncture can involve intensive needling, Manheimer continued, “and this insertion of needles, even if they are not in the right place and even if it’s just superficial, may have some physiological or biological effects.” He suspects that this could partly explain why there was no difference between the effect of sham and real acupuncture in the two trials that used a particularly intensive version of fake needling.

Despite the finding that much of the benefit of acupuncture appears to be due to patients’ expectations, Manheimer and colleagues concluded that acupuncture “seems to have a genuine biological effect suggested by the small short-term improvements in pain and function shown in the trials compared with sham.” In addition, no adverse effects were reported in the trials, which is more than can be said about the painkillers.

“Like acupuncture, many prescription painkillers have benefits that are too small to be meaningful to patients,” said Manheimer. “Given the limited treatment options available for patients with arthritis and the possibility of a slight short-term benefit of acupuncture, some might consider acupuncture as one treatment option in a multidisciplinary approach to treating knee osteoarthritis.