Arthritis: Understanding the Role of Medication
by Jan Revella, R.N.

  Hundreds of medications are available to treat arthritis, and it seems as if new ones are coming on the market every day. People often ask me, "Which is the best one to use?" The answer is that there is no "best" medication. They all work in different ways on different types and symptoms of arthritis. Each has an expected benefit, and the potential for side effects.

  It's very important that you and your doctor communicate effectively in order to choose the most appropriate arthritis medication for you. For example, because some arthritis medications have been associated with birth defects, a rheumatologist needs to consider whether his patient is a 32-year-old woman who plans to have children, or a 65-year-old who will not have any more children. Drinking alcohol can increase the risk of stomach ulcers from some arthritis medications. People with impaired kidney function should not take certain arthritis medications, because they can interfere with kidney function. Many people with arthritis, particularly older adults, often are taking several different prescription medications for other conditions as well as the arthritis medication. This could set the scene for potential drug interactions that could have serious effects. If you are in a managed care insurance plan, certain arthritis medications will be included on your plan's formulary (list of approved medications) and others will not. For some patients it may be easier to take their medication once a day, rather than remembering to take it four times a day. Finally, some patients would prefer a less expensive generic version to make it easier on their budget.

  A good rheumatologist will learn all these things about his or her patients and consider these factors when prescribing arthritis medication.

  Here's a quick overview of the main categories of arthritis medication and their characteristics. We've also listed individual medications by category.

Arthritis Medication Categories

 Non-steroidal anti-inflammatory drugs (NSAIDs) are the most widely prescribed arthritis medications today. They block substances called prostaglandins that promote inflammation and pain. NSAIDs are known to cause harmful effects on the stomach, leading to ulcers and bleeding. In fact, 15,000 deaths occur each year due to chronic NSAID use. These drugs cannot differentiate between the prostaglandins that promote inflammation and the good prostaglandins we need to protect our stomach lining and kidney function. When decreasing all prostaglandins, NSAIDs put certain patients at risk. Recently, a new category of NSAID called COX-2 inhibitors was introduced (Celebrex, Mobic and Vioxx). These new drugs target only the inflammation-related prostaglandins, making them safer for the stomach and kidneys. NSAIDs can relieve the symptoms of arthritis but do not alter the progression of the disease itself.

   Salicylates are aspirin-based medications that relieve pain and inflammation. They also can lead to stomach, kidney and bleeding problems, but are available in forms that minimize this potential.

   Glucocorticoids are powerful cortisone-based drugs that fight inflammation. Because they suppress the immune system, they are beneficial in patients with rheumatoid arthritis (RA) and lupus. They can be given orally, by IV or as an injection. When a steroid is considered in the course of treatment it is given serious thought.

   Biologic response modifiers are more targeted agents that inhibit the immune responses related to arthritis, while sparing other immune system function. The two drugs in this category are Enbrel and Remicade.

   Unlike NSAIDs, disease-modifying antirheumatic drugs (DMARDs) actually work to stop the progression of inflammatory joint disease. They are used primarily in inflammatory conditions such as RA, lupus, psoriatic arthritis and ankylosing spondylitis. They are not appropriate for degenerative conditions such as osteoarthritis. DMARDs are a good first line of defense for people newly diagnosed with inflammatory arthritis, since they can help keep the damage from progressing. Arava, the first new drug approved for RA in 10 years, is a DMARD.

   Viscosupplements consist of two drugs, Synvisc and Hyalgan, recently approved by the Food and Drug Administration (FDA) for treatment of knee (only) osteoarthritis. By replacing hyaluronic acid, the substance that lubricates the joint, they help reduce pain. Both are injected directly into the knee joint.

   Analgesics provide simple pain relief. Acetaminophen (Tylenol) is an example. Topicals such as BenGay and the new creams based on capsaicin, the active ingredient in chile peppers, also belong here.

  The other categories include drugs for fibromyalgia, gout and osteoporosis.

  The main thing to understand is that if you're being treated for a chronic problem, such as arthritis, simply treating it with medication over the long term increases your risk of developing side effects. Try to stay away from medications as much as you can, but don't put your comfort at risk. Take a balanced, active approach to managing arthritis that includes exercise and joint protection as well as medication. It's important to design a treatment program based on your individual goals.

Arthritis Medications By Category

Analgesics
Acetaminophen (Aspirin-Free Anacin, Excedrin, Panadol, Tylenol), Acetaminophen with Codeine (Fioricet, Phenaphen with Codeine, Tylenol with Codeine), Propoxyphene hydrochloride (Darvon, PC-Cap, Wygesic), Tramadol (Ultram)
Topical Analgesics: ArthriCare, Aspercreme, Ben Gay, Capzasin-P, Flex-all, Icy Hot, Therapeutic Mineral Ice, Zostrix

Biologic Response Modifiers
Etanercept (Enbrel), Infliximab (Remicade)

Disease-Modifying Antirheumatic Drugs (DMARDs)
Azathioprine (Imuran), Cyclophosphamide (Cytoxan), Cyclosporine (Neoral, Sandimmune), Hydroxychloroquine sulfate (Plaquenil), Methotrexate (Rheumatrex), Leflunomide (Arava), Minocycline (Minocin), Penicillamine (Cuprimine, Depen), Sulfasalazine (Azulfidine)
Oral or injectable gold: Auranofin (Ridaura), Gold sodium thiomalate (Myochrysine), Aurothioglucose (Solganol)

Fibromyalgia Medications
Antidepressants: Amitriptyline hydrochloride (Elavil, Endep), Doxepin (Adapin, Sinequan), Fluoxetine (Prozac), Nortriptyline (Aventyl, Pamelor), Paroxetine (Paxil), Sertraline (Zoloft)
Muscle relaxants: Cyclobenzaprine (Cycloflex, Flexeril)

Glucocorticoids
Cortisone (Cortone acetate), Dexamethasone (Decadron, Hexadrol), Hydrocortisone (Cortef, Hydrocortone), Methylprednisolone (Medrol), Prednisolone (Prelone), Prednisone (Deltasone, Orasone, Prednicen-M, Sterapred), Triamcinolone (Aristocort)

Gout Medications
Allopurinol (Lopurin, Zyloprim), Colchicine, Probenecid and Colchicine (ColBenemid, Proben-C, Col-Probenecid), Probenecid (Benemid, Probalan), Sulfinpyrazone (Anturane)

Osteoporosis Medications
Alendronate (Fosamax), Calcitonin (Calcimar, Miacalcin), Conjugated Estrogens (Premphase, Prempro, Premarin), Esterified Estrogens (Estratab, Menest), Raloxifene hydrochloride (Evista), Risedronate (Actonel)

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Diclofenac potassium (Cataflam), Diclofenac sodium (Voltaren), Doclofenac sodium with misoprostol (Arthrotec), Diflunisal (Dolobid), Etodolac (Lodine), Fenoprofen calcium (Nalfon), Flurbiprofen (Ansaid), Ibuprofen (Motrin, Advil, Motrin IB, Nuprin), Indomethacin (Indocin), Ketoprofen (Orudis, Oruvail, Actron, Orudis KT), Meclofenamate sodium (Meclomen), Mefenamic acid (Ponstel), Nabumetone (Relafen), Naproxen (Naprosyn, Naprelan, Naprosyn-E), Naproxen sodium (Anaprox, Aleve), Oxaprozin (Daypro), Piroxicam (Feldene), Sulindac (Clinoril), Tolmetin sodium (Tolectin)
COX-2 Inhibitors: Celecoxib (Celebrex), Meloxicam (Mobic), Rofecoxib (Vioxx)

Salicylates
Aspirin (Anacin, Ascriptin, Bayer, Bufferin, Ecotrin, Excedrin), Choline magnesium trisalicylate (CMT, Tricosal, Trilisate), Choline salicylate (Arthropan), Magnesium salicylate (Magan, Doan's Pills, Mobidin, Arthritab), Salsalate (Disalcid, Mono-Gesic, Salflex, Salsitab, Amigesic, Anaflex 750, Marthritic), Sodium salicylate

Viscosupplements
Hyaluronan (Hyalgan), Hylan G-F 20 (Synvisc)

About the author:
Jan Revella, R.N., Arthritis Nurse Specialist, is founder and director of Arthritis Education by Professionals, Inc., based in Phoenix, Arizona. She is among the most prominent speakers and educators on the subject of arthritis in the United States. Her mission is to empower people with arthritis to use knowledge as power when making decisions about their personal healthcare. Arthritis Education by Professionals, Inc. provides educational programs and services to people with arthritis.

© Copyright 2005. Arthritis Education by Professionals, Inc.


Medical Information Disclaimer
   The material contained in this Web site is furnished for educational purposes only, and should not be taken as a substitute for the advice of a healthcare professional. It is not intended for diagnosing or prescribing. Consult your physician before practicing any recommendations or acting on any information contained in this site. Always consult your physician before beginning any exercise or treatment program. Arthritis Education by Professionals, Inc. denies any responsibility or liability for any adverse consequences or damages resulting from reliance on the information contained in this site.