Role of medication in managing arthritis

Medication is an important element in helping manage arthritis but it is just one way of managing your condition. Its success will be determined by many factors, including taking responsibility for other aspects of your life as well. At present there is no known cure for arthritis so your medication will help with the symptoms or slowing the progress of the disease. You may also have to take other medications to reduce side effects.

The treatment of your arthritis is a team effort, so your doctor will be depending on you for several things - giving the information about how you are feeling, taking your medication as prescribed, noting the effects it has on your body (both good and not so good), and keeping your doctor in touch with how your health is progressing.

Finding the safest, most effective drug treatment often requires some trial and error and requires two-way communication between you and your doctor. When the doctor prescribes medication, you should be given some basic information about what to expect and possible side effects, or you may receive this information from your pharmacist.

It is important to understand as much as possible about your medication. Ask about possible side effects, how long does it take for the drug to work, what happens if you miss a dose, is it affected by drinking alcohol and what is the best way to take it (ie. with food or not).

Main types of arthritis medications:

• analgesics
• non-steriodal anti-inflammatory drugs (NSAIDs)
• Cox-2 inhibitors
• corticosteroids
• disease-modifying anti-rheumatic drugs (DMARDs)
• biologic response modifiers (BRMs).

 Analgesics (pain-killers)
These drugs are simple in the sense that they do not have an anti-inflammatory effect, as do NSAIDs. They are pain relievers only. These drugs are most commonly prescribed for osteoarthritis and other non-inflammatory, but painful forms of arthritis. Often they can be purchased over-the-counter.

These pain relievers may contain paracetamol, codeine, aspirin or a combination. There are very few side effects if taken as prescribed although aspirin may irritate the stomach (aspirin is also classed as an NSAID). Codeine can cause constipation and nausea. Do not use more than the recommended dose or for prolonged periods of time without medical advice.

Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs are used to help relieve the inflammation, swelling, stiffness and joint pain associated with arthritis and form the largest and most widely used category of medications for arthritis. They are effective in relieving these symptoms, but do not alter the course of arthritis nor do they stop the progression of joint damage.

NSAIDs work by blocking the production of prostaglandins, hormone-like substances that contribute to pain and inflammation. Salicylates, including aspirin, are a part of this group and for many years were the only type of NSAID available over-the-counter. Many others, including ibuprofen, are now also available for purchase.

The major side effect of these drugs is stomach upsets such as irritation and ulcers. They should always be taken with food or a glass of milk. Often it will be necessary to prescribe other medications to help with these stomach upsets.

If a NSAID is proving effective, you should feel some improvement in pain and stiffness within a week. Although no major differences in effectiveness have been demonstrated between the NSAIDs available, individual patients sometimes find one drug to be very much more effective than another. It may be necessary to compare several different NSAIDs over a period of time before finding the one most suitable for you.

Cox -2 inhibitors
Cox-2 inhibitors are a newer type of medication which assist in the reduction of pain and inflammation. They work in a similar way to NSAIDs, but may be preferable in patients at risk of stomach problems from NSAIDs, as they have a lower likelihood of causing stomach ulcers. [Unlike most analgesics and NSAIDs, which are subsidised to some extent, cox-2 inhibitors must be paid for in full by the patient.]

Corticosteroids
For more than 50 years corticosteroids have played an important role in the treatment of rheumatoid arthritis and other inflammatory diseases.

Injections
Corticosteroids are injected into a joint, such as an elbow or knee, to rapidly relieve the inflammation and swelling from arthritis and to improve mobility. Low, well-spaced doses of injected corticosteroid are thought to produce little risk of significant side effects.

Tablets
Doctors sometimes prescribe oral corticosteroids in the short term to relieve acute symptoms of arthritis, with the goal of gradually tapering off the medication. Prednisone is probably the best known oral corticosteroid.

Side effects - long term use
Similar to a hormone which is produced by the body, corticosteroid medications have the ability to reduce harmful or even life-threatening inflammation of the joints, blood vessels and organs. But they also carry some harmful side effects, particularly when given over long periods of time.

Corticosteroids (unlike the anabolic steroids used by some athletes) break down musculo-skeletal tissues. This effect increases with higher doses and longer periods of treatment. The skin may then become weakened (bruises more easily and heals poorly) and bones may develop osteoporosis with increased susceptibility to fracture (especially in the elderly).

Cataracts in the eye can result from prolonged use and glaucoma can worsen. These effects are less likely to become important on doses of less than 10mg per day, but no dose level is completely free of such effects if taken for a long period of time.

To reduce corticosteroid side effects, doctors usually reserve high doses for short-term use during flare ups. Because they work so quickly - often within a couple of days, many doctors prescribe them as a temporary measure while waiting for other drugs to take effect.

Prednisone should never be stopped suddenly as the body cannot cope and you should carry information on their dosage in case of emergency.

Disease-modifying anti-rheumatic drugs (DMARDs)
These are standard drugs for the treatment of moderate to severe rheumatoid arthritis in most western countries. DMARDs are commonly used to limit the amount of joint damage that occurs in arthritis. They may also be prescribed for other inflammatory diseases including lupus, ankylosing spondylitis, and Sjogren's syndrome.

Unlike NSAIDs, DMARDs have the potential to suppress the activity of rheumatoid arthritis, but have no effect on symptoms. There can be a delay of sometimes 3-6 months before any improvement occurs. Because of this, DMARDs are often used with a NSAID or corticosteroid so that immediate symptoms are relieved. DMARDs have a success rate of about 40% and it is common for a patient to require a trial of more than one of the groups of these drugs before a response is seen.

While DMARDs offer the possibility of significant benefit in rheumatoid arthritis and other forms of inflammatory arthritis, it must be appreciated that all can be associated with serious side effects such as the ability to fight infection or stomach upsets. Always discuss these with your doctor - and if in doubt, check it out.

Pregnancy and DMARDs
There is concern that some DMARDs may harm the development of an unborn child, so sexually active women should be using an effective means of contraception. There is also concern that DMARDs may reduce the effectiveness of contraceptives. If pregnancy should occur while taking this type of drug, pregnancies are usually successful. However, if you intend to become pregnant you should plan this carefully with advice from your doctor. Fertility may also be reduced for men taking some DMARDs.

Biologic response modifiers (BRMs)
BRMs are used to relieve hard-to-treat pain and inflammation of severe arthritis and to limit the amount of joint damage.

Deciding on drug treatment

The drug of first choice is dependent on the severity of your arthritis, the presence of other disorders or drug treatments and the risk of side effects. Provided the particular drug is tolerated, it is important to continue for the full trial period even if no improvement is apparent in the first few weeks.

If improvement occurs and if your arthritis continues to be suppressed, therapy may be continued for a number of years. If the drug of first choice is not effective after an adequate trial, a second trial may be indicated. 

Original material provided by Arthritis New Zealand. Reviewed by everybody, July 2005.