Every day more than 300 million people around the world take medications for pain relief. Of these, nearly 80 million take pain relievers prescribed by their doctors; the rest use over-the-counter products. Rheumatoid arthritis and osteoarthritis patients consume about a third of all pain relievers sold worldwide.

Medications called NSAIDs provide some relief from the pain of RA. NSAID stands for "nonsteroidal anti-inflammatory drug." Nonsteroidal means that the medication contains no steroid drug, such as prednisone or cortisone. Anti-inflammatory means that the medication reduces inflammation by diminishing swelling, pain and redness. NSAIDS alleviate discomfort but they do not slow the progression of RA, so they are used along with disease modifying drugs. Some NSAIDs require a prescription. Low dose NSAIDs are available over-the-counter. Popular over-the-counter NSAIDs include:

Aspirin

Aspirin, the best-known NSAID, has been in use since before the Food and Drug Administration was founded. It is available over-the-counter in capsules or in chewable, safety coated or non-coated tablets. Aspirin provides relief for inflammation, pain and fever.

Ibuprofen, Ketoprofen and Naproxen

Ibuprofen is available over-the-counter branded as Advil®, Motrin®, Motrin IB®, Medipren®, Arthritis Foundation Ibuprofen®, and Nuprin®. Ketoprofen is branded as Orudis®. Naproxen's over-the-counter brand is Aleve®. Ibuprofen, ketoprofen and naproxen relieve inflammation, pain and fever.

Meloxicam (Mobic®), a new NSAID, was approval by the FDA in April, 2000. Like other NSAIDS, it relieves inflammation, pain and fever.

Acetaminophen: Not an NSAID

Acetaminophen, branded as Tylenol® and other products, is a popular pain reliever. However, it is not classified as an NSAID because it works in a different way. While it relieves pain and fever as well as aspirin does, acetaminophen does not suppress inflammation.

NSAIDs suppress the enzyme, cyclooxygenase (pronounced si-klo-OX-suh-juhn-ays). This enzyme, known as COX, mediates the production prostaglandin, which triggers inflammation and pain. There are two kinds of COX. COX-1 is found throughout the entire body, but especially in the gastrointestinal tract, where it has a protective function. COX-2 is found only in inflamed tissue. NSAIDs inhibit both forms of COX.

When NSAIDs are used occasionally and taken according to label directions, there are usually no serious problems. Problems can occur, however, with long-term use. This is because NSAIDs suppress COX-1 as well as COX-2. Long-term use of NSAIDs reduces the important protective function of COX-1 in the GI tract. Serious side effects include damage to the lining of the stomach, such as ulcers and bleeding, kidney dysfunction and abnormal blood platelets.

About 20% of those who take NSAIDs on a regular basis develop ulcers. Between 1-2% of people who use aspirin experiences intestinal tract hemorrhaging. Other problems can include nausea, abdominal pain, diarrhea, vomiting, headache, increased blood pressure, ringing in the ears, dizziness or skin rash. People who take NSAIDs are five times more likely to be hospitalized with GI problems than people who don't use them. The American Journal of Medicine published a study that focused on the relationship between NSAID complications and hospital admissions. The study revealed that 107,000 people are admitted to hospitals every year with NSAID-related problems, some serious enough to cause death.

NSAID complications may be reduced by following these safety tips:

Always take the lowest dose of NSAID that brings relief for you.

Don't take NSAIDs on an empty stomach. Take these medications at mealtimes or with food at other times.

Stop taking NSAIDs before any surgical procedure. Aspirin should be stopped 10-14 days ahead of time. Naproxen should be stopped 5 days ahead; ibuprofen and ketoprofen two days ahead.

Don't take two NSAIDs at the same time. Its OK to take an NSAID and acetaminophen together for a short time if your doctor approves.

Don't drink alcohol while taking NSAIDs. (It can increase the risk of bleeding.)

Discuss NSAIDs with your doctor if you have: diabetes, peptic ulcer, high blood pressure, asthma, a bleeding disorder, or problems with your liver, heart, kidneys or vascular system. If you are taking other medications or are pregnant or nursing you should also talk to your doctor about which NSAIDs are safe for you.

A new class of pain relief medications has recently been approved by the Food and Drug Administration. These drugs are called COX-2 selective inhibitors, because they suppress only the problematic COX-2 enzyme. The COX-1 enzyme is not inhibited, so its protective function in the GI tract is not disturbed. Like NSAIDs, COX-2 drugs relieve pain and reduce inflammation, but they are safer, causing fewer gastrointestinal problems like ulcers or bleeding.

The first COX-2 drugs, Celebrex and Vioxx, were approved in 1999. Celebrex was specifically approved for RA; Vioxx was approved for other conditions, but many doctors may prescribe it for RA as well. COX-2 drugs have been nicknamed "super aspirins." However, they are not aspirin, nor are they more effective than NSAIDs. Their big plus is safety. However, people who are allergic to aspirin should not take either drug, and those who are allergic to sulfa should avoid Celebrex. The COX-2 drugs should not be taken along with any NSAID, either over-the-counter or prescribed. The one exception could be a low dose of aspirin that is taken daily to prevent heart attacks. COX-2 inhibitors may put susceptible patients at risk for coronary artery disease and strokes.

The COX-2 drugs, like NSAIDs, do not have any effect on the underlying disease of RA and should be taken along with disease modifying drugs. Celebrex and Vioxx are more costly than NSAIDs, but their added safety may make them an attractive alternative for many RA patients. Those who may benefit most from COX-2 drugs are people at high risk for NSAID complications, including:

Smokers

People who are older than 60

Those who have ulcers or who have had them in the past

People taking cortisone-type drugs along with NSAIDs

Many people address RA pain with topical pain relief products. Topical treatments give temporary relief and are available over-the-counter. They are rubbed or sprayed onto the skin over a painful joint.

Topical pain relief products like Zostrix contain capsaicin, a natural substance obtained from hot peppers. Capsaicin works by inhibiting a chemical called substance P in the nerve endings of the skin. Substance P is apparently involved in transmitting pain signals to the brain and also in creating inflammation. Other topical treatments contain salicylate, the same pain reliever contained in aspirin. Salicylate seem to diminish the capacity for pain in the nerve endings of the skin. Irritants are also used in topical treatments. Irritants act as a decoy, causing sensations of cold, warmth or itching which mask pain. Menthol, camphor, turpentine oil and histamine dihydrochloride are examples of irritants.

RA patients should be aware of a few safety tips concerning topical pain relievers:

To avoid burns, after applying a topical pain reliever don't cover the area with a bandage or use a heating pad.

Wash the hands after application to avoid transferring the product to the eyes or other sensitive areas of the body.

People who are allergic to aspirin or who are taking blood thinners should discuss topical pain relievers with their doctors.

References

First published September 1, 1999
Last updated December 16, 2002
Copyright © 1999 Accordant Health Services, Inc. All Rights Reserved.

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