What medications are used to manage arthritis pain?

Medications for Managing Arthritis Pain

Initial treatment for painful joints attributed to arthritis should be paracetamol (acetaminophen) in doses of up to 4 g daily, followed by ibuprofen if paracetamol fails to provide adequate relief. 1, 2

First-Line Treatment Options

Acetaminophen/Paracetamol

• Recommended as first-line therapy for osteoarthritis pain management 1, 2
• Dosage: Up to 3-4g/day (maximum)
• Better safety profile than NSAIDs, although somewhat less effective 2
• Particularly appropriate for elderly patients and those with comorbidities
• Provides modest pain relief with minimal side effects 3

Topical NSAIDs

• Strongly recommended, particularly for elderly patients or those with comorbidities 2
• Provides localized pain relief with fewer systemic side effects than oral NSAIDs
• Good option for patients with single or few affected joints

Second-Line Treatment Options

Oral NSAIDs

• If paracetamol fails to relieve symptoms, ibuprofen is the most appropriate alternative at a dose of 1.2 g daily 1
• Ibuprofen has the lowest risk of gastrointestinal complications among NSAIDs 1
• For inadequate relief, the dose of ibuprofen may be increased to 2.4 g daily 1
• NSAIDs are superior to acetaminophen for improving knee and hip pain in people with moderate-to-severe osteoarthritis 3
• Alternative NSAIDs such as diclofenac or naproxen may be considered if ibuprofen is ineffective 1, 2

Combination Therapy

• Paracetamol may be added to NSAIDs for enhanced pain relief 1
• The combination provides complementary mechanisms of action

Advanced Treatment Options

Intra-articular Corticosteroid Injections

• Conditionally recommended for acute pain flares, particularly with joint effusion 2
• Provides temporary relief while continuing rehabilitation
• Effective for short-term pain management in inflammatory flares

Hyaluronic Acid Injections

• Conditionally recommended for patients with inadequate response to initial therapy 2
• Can provide pain relief and functional improvement for up to six months

Tramadol

• Conditionally recommended when acetaminophen/NSAIDs are ineffective or contraindicated 2
• Allows reduction of NSAID dose in patients with NSAID-responsive pain
• Should be used cautiously due to side effect profile and risk of dependence

Special Considerations

Gastrointestinal Risk

• Patients taking traditional NSAIDs are 1.47 times more likely to experience adverse GI events compared to those taking acetaminophen 3
• Consider gastroprotective agents (H2 blockers, proton pump inhibitors) for patients at high risk of GI complications 1
• Routine prophylaxis for NSAID-induced gastrointestinal injury is not appropriate for all osteoarthritis patients 1

Cardiovascular Risk

• For patients with cardiovascular risk, celecoxib (100mg twice daily) has non-inferior cardiovascular safety compared to ibuprofen and naproxen 2
• Naproxen may be preferred in patients with high cardiovascular risk 2

Renal Risk

• NSAIDs should be used with caution in patients with renal impairment 2
• Consider acetaminophen or topical NSAIDs as alternatives

Treatment Algorithm

1. Start with acetaminophen/paracetamol (up to 4g/day)
2. If inadequate relief, add or switch to ibuprofen (1.2g/day initially)
3. For continued inadequate relief:
   • Increase ibuprofen to 2.4g/day, or
   • Add paracetamol to ibuprofen, or
   • Switch to alternative NSAIDs (diclofenac, naproxen)
4. For persistent pain:
   • Consider intra-articular corticosteroid injections for acute flares
   • Consider hyaluronic acid injections
   • Consider tramadol (with caution)

Common Pitfalls to Avoid

• Overreliance on opioids for chronic arthritis pain management
• Inadequate dosing of initial therapies before moving to more potent options
• Failure to discuss potential risks of side effects with patients before starting or changing treatment 1
• Not considering the patient's comorbidities (cardiovascular, renal, gastrointestinal) when selecting medications
• Using high-dose NSAIDs for extended periods without monitoring for adverse effects

Remember that pharmacological management should be combined with non-pharmacological approaches such as exercise, weight loss (if overweight), and physical therapy for optimal outcomes 2.