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health canada-approved treatments: osteoarthritis
10 minute read
as experts note, long-term management of osteoarthritis includes a focus on education, weight management and exercise.
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this article is for informational purposes only and is not intended to provide medical advice, diagnosis or treatment. always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
osteoarthritis is the most common form of arthritis that occurs when the cartilage that protects and cushions the ends of your bones gradually deteriorates, damaging your joints. known as a chronic degenerative disease, the condition can affect any joint but usually impacts joints in your hands, hips, knees and spine. as it progresses, the disease can change your gait and posture, leading to mobility issues and chronic pain.
while it’s widely perceived as an older person’s disease – risk increases with age – younger people make up a significant number of the more than four million canadians who live with osteoarthritis. about one-third of people report being diagnosed before age 45, and over half (52 per cent) of people who have osteoarthritis are younger than 65.
obesity is the predominant risk factor that explains the rising number of younger people being diagnosed. extra weight puts additional stress on weight-bearing joints, and fat tissue produces proteins that can cause inflammation in and around your joints. the same fat-related inflammatory proteins are involved in heart disease, diabetes and depression.
another risk factor that clinicians are seeing more of is repeated stress and injuries to joints from sports. even injuries that happened years ago and have since healed increase the risk of osteoarthritis. and some people inherit a genetic predisposition or are born with bone deformities or defective cartilage which make them more susceptible to developing the degenerative disease.
metabolic diseases like diabetes and hypertension can also put people at higher risk of osteoarthritis because these diseases share the same mechanisms of inflammation and oxidative stress that can damage bone and cartilage.
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symptoms of osteoarthritis include:
- pain, where affected joints hurt during or after movement
- stiffness in joints, most noticeable when you awaken or after being inactive
- joint swelling and tenderness
- loss of flexibility
- grating sensation when you use the joint with possible popping or crackling noise
- bone spurs that feel like hard lumps can form around affected joints
these disruptive symptoms lead to fatigue, sleep disturbance and depression, and can have an enormous burden on daily function and quality of life. while there’s no cure for osteoarthritis, earlier detection offers a better chance of changing the course of the disease, so there’s a growing focus on prevention. the underlying process of osteoarthritis and joint damage can’t be reversed, but symptoms often can be improved significantly with self-management strategies, including physical activity, healthy eating and weight management, and medications. surgery may be an option in severe cases where people fail to improve with self-management.
here’s a look at the treatment options available for canadians.
prescription medications
steroid injections
steroid injections, belonging to the corticosteroid class of drugs, are used to help relieve the pain and swelling of osteoarthritis. injecting a steroid in or around the joint is an effective way to locally reduce pain and swelling. brand names for these injections include depo-medrol, kenalog, aristospan and celestone soluspan.
corticosteroids are synthetic forms of the cortisone hormone that helps reduce inflammation. so, when corticosteroids are injected directly into a joint, they can reduce pain, swelling and redness at the site. if you respond well to the first injection, you may benefit from another. the general rule is to limit injections to three or four for any single joint per year. but experts are also cautious about overuse damaging cartilage, so continued injections are not recommended as a long-term therapy.
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most injections cause temporary joint discomfort that improves in 24 hours and can be treated with a cold pack or pain-reliever medication. patients are advised to rest the joint up to 48 hours after the shot. the relief provided varies for patients with some feeling better for months while others experience symptom improvement for only a few days.
the injections rarely injure a joint or tendon but can cause a rise in blood sugar, mostly in people with diabetes. for this reason, a routine blood test sometimes follows an injection to check blood sugar levels. meeting with your healthcare provider regularly will monitor pain control and effectiveness of the injection.
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duloxetine
duloxetine is used to treat a number of chronic pain conditions including osteoarthritis, nerve disorders, chronic low back pain and fibromyalgia. under the brand name cymbalta, it was originally approved for treatment of depression and belongs to a group of medicines called serotonin and norepinephrine reuptake inhibitors, or snris, which are widely prescribed for depression and anxiety.
for osteoarthritis, duloxetine is a second-line treatment for patients who don’t respond to or can’t tolerate acetaminophen or nsaids. it’s been shown to have modest to moderate effects on pain relief, function improvement, mood regulation and improvement in quality of life.
higher doses of duloxetine are linked to a higher rate of adverse reactions. the recommended dose is 60 mg once daily to a maximum of 120 mg daily, but patients commonly start duloxetine on 30 mg once daily, with a dose increase to 60 mg in one to two weeks to adjust to the medication. those with impaired kidney function may need a lower dose ongoing.
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initial side effects from duloxetine usually subside in one to two weeks after starting the medication. side effects can include the following:
- nausea
- constipation
- dry mouth
- fatigue
- dizziness
- drowsiness
- increased blood pressure and heart rate
- sweating
- decreased appetite
also, suicidal thoughts and self-injury have been very rarely reported in patients taking snri medications like duloxetine. speak to your health-care provider if you experience worsening depression or thoughts of suicide while taking duloxetine. don’t stop or reduce your dosage without consulting your health-care provider. duloxetine should be discontinued slowly over the course of two weeks.
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viscosupplementation
knee osteoarthritis can benefit from viscosupplementation, where a clear gel-like substance containing hyaluronic acid is injected into the knee. hyaluronic acid is produced by your body naturally, and found throughout your body, especially in eyes, joints and skin. it’s commonly used in skincare products because it is effective for healing and hydration. the gooey substance is also found in the synovial fluid of the knee joint, so injection of formulations like cingal, monovisc or orthovisc lubricates the cartilage, just like oil lubricates an engine, leading to reduced pain.
in osteoarthritis, the cartilage cap of the knee breaks down and the bones of your joint scrape together abnormally. people with osteoarthritis generally have less hyaluronic acid in their joints than they should, causing symptoms of pain, stiffness and swelling. viscosupplementation replaces this hyaluronic acid to help reduce symptoms. the treatment appears to work best in people with mild or moderate arthritis, and can make sense if you are trying to delay getting surgery on your joint. a single injection of cingal and monovisc or three injections of orthovisc can help reduce knee pain from osteoarthritis for up to six months. cingal also contains a corticosteroid to help relieve pain.
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prescription nonsteroidal anti-inflammatory drugs (nsaids)
nsaids are a class of medication for pain and inflammation of arthritis that don’t contain steroids. they comprise a large category of medications, where stronger doses of common over-the-counter options like acetylsalicylic acid (aspirin, entrophen, novasen), ibuprofen (motrin or advil) and naproxen (aleve) are available by prescription. the long-term use of these medications, especially at higher doses, is not recommended because of potential impact on your stomach lining, kidneys and heart.
a coxib (celebrex) is a nsaid that has been custom-designed to minimize the risk of stomach ulcers. while coxibs are safer on the stomach, they still have all of the other side effects of nsaids and may still cause side effects including:
- indigestion
- nausea
- stomach cramps
- heartburn
two nsaid pills – etoricoxib 60 mg/day and diclofenac 150 mg/day – are suggested to be among the best options for most people with osteoarthritis, although, again, not for long-term use or for people with certain other health conditions.
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over-the-counter medications
topical creams, gels and patches
patients often start with topical treatments like capsaicin cream, such as rub a-535, capsaicin cream or zostrix, especially if they are reluctant to use oral medications. capsaicin is found in hot peppers and offers anti-inflammatory therapy. the cream formulation can be applied directly to the skin of the problematic joint. the typical dose is to apply sparingly three or four times daily and massaging into the area.
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it’s considered best for people who have osteoarthritis in only one or two joints, like the hand or knee. capsaicin cream can also be tried in combination with oral drugs if more pain relief is needed.
these topicals should not be used on irritated or raw skin. a test patch is recommended to check for a rash or adverse reaction. skin stinging or redness can occur during the first week of treatment; this often prevents long-term use. using external heat, like a hot water bottle or heating pad, or even sweating through exercise, can lead to excessive skin irritation or burn.
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acetaminophen
in osteoarthritis, pain relief helps patients cope with the disease and carry on with daily functions. acetaminophen is in a class of medications called analgesics, or pain relievers, and antipyretics, which reduce fever. it changes the way your body senses pain and also has a cooling effect. there are many name brands for acetaminophen, with tylenol leading the market.
acetaminophen is one of the most common medications for osteoarthritis because of its effectiveness and the fact that it has fewer side effects than other pain medications. however, high doses are associated with liver toxicity. patients with liver disease or alcoholism should avoid it or use less than the recommended dose in consultation with a healthcare provider. it can build up and become toxic if your liver function is impaired, leading to drug-induced hepatitis.
for safe use of acetaminophen, follow the dosing schedule. adults should not take more than 4,000 mg in a day, and also not use other drugs containing acetaminophen without first asking their healthcare provider. the drug ingredient is found in more than 600 different over-the-counter and prescription drugs for pain, fever and cough and cold symptoms, so always check the label before taking another medication with acetaminophen.
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nonsteroidal anti-inflammatory drugs (nsaids)
nsaids can reduce pain and inflammation in osteoarthritis, and many are available over-the-counter, including ibuprofen, such as advil and motrin, and naproxen sodium, such as aleve. stronger nsaids are available by prescription, but patients usually start with the lower-dose options because there are potential side effects including:
- diarrhea
- headaches
- stomach irritation
these medications are not advised for long-term use. they can lead to more severe, chronic complications like stomach ulcers and kidney problems. some patients are advised to take it in combination with acetaminophen for better results and to explore other options for long-term treatment, including regular physical activity and weight management.
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surgery
most patients manage their osteoarthritis symptoms with medicine and lifestyle changes. but surgery may be an option when patients experience very bad pain, have lost a lot of cartilage, or have tried medicine and other treatments that haven’t worked for them
the most common surgeries for osteoarthritis include hip and knee replacements, but other joints may be partially or fully replaced surgically as well. joint replacement surgery is usually reserved for patients with advanced osteoarthritis. surgery may not be helpful for patients who only have mild arthritis, even if they have significant pain.
there are drawbacks to this approach and benefits and risks should be discussed with your healthcare provider. joint replacement is not a cure for osteoarthritis, and as many as 20 to 30 per cent of hip or knee replacement recipients report little or no improvement in their symptoms and dissatisfaction with their surgical results one year after joint replacement.
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physiotherapy and occupational therapy
non-pharmacological interventions are an important part of a treatment plan for osteoarthritis. physiotherapy helps with pain and ensures patients stay mobile. a physical therapist shows you how to strengthen muscles around joints and increase your flexibility. in addition, regular gentle exercises that you can do independently, like swimming and walking, can also be effective.
occupational therapy helps people live as independently as possible. an occupational therapist shows you ways to carry out daily tasks without putting extra stress on painful joints.
as experts note, long-term management of osteoarthritis includes a focus on education, weight management and exercise. these non-pharmacological treatments complement medication to improve pain, function and independence.
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