What are the recommended pain medications for shoulder osteoarthritis?

Pain Medication for Shoulder Osteoarthritis

Start with acetaminophen (paracetamol) as your first-line pharmacologic treatment for shoulder osteoarthritis pain, using regular dosing up to 4000 mg daily, as it provides effective pain relief with the best safety profile. 1

First-Line Pharmacologic Treatment

• Acetaminophen should be the preferred initial medication for mild to moderate shoulder OA pain, with regular dosing potentially needed throughout the day 1
• The maximum daily dose is 4000 mg (4 grams), though some guidelines suggest staying at or below 3000 mg daily in elderly patients for enhanced safety 1, 2
• Acetaminophen provides comparable pain relief to NSAIDs for mild-to-moderate OA pain without the gastrointestinal, renal, and cardiovascular risks 1, 3

Second-Line Options When Acetaminophen Fails

Topical NSAIDs

• If acetaminophen provides insufficient relief, consider topical NSAIDs (such as diclofenac gel) before oral NSAIDs, as they have minimal systemic absorption and lower risk of adverse effects 1, 2
• Topical capsaicin is an alternative topical agent that may provide localized pain relief 1

Oral NSAIDs or COX-2 Inhibitors

• When topical treatments are inadequate, add or substitute with oral NSAIDs or COX-2 inhibitors at the lowest effective dose for the shortest possible duration 1
• NSAIDs are more effective than acetaminophen for pain reduction (effect size 0.20), particularly for moderate-to-severe pain, but carry significantly higher risks 3, 4
• Always prescribe a proton pump inhibitor alongside oral NSAIDs or COX-2 inhibitors for gastroprotection, choosing the one with lowest cost 1

Critical Safety Considerations

Risk Assessment Before NSAIDs

• Carefully assess cardiovascular, gastrointestinal, and renal risk factors before prescribing any oral NSAID, particularly in patients over 50 years 2, 5
• Elderly patients face substantially higher risks of GI bleeding, renal insufficiency, platelet dysfunction, and cardiovascular complications with NSAIDs 1
• NSAIDs should never be used in high doses or for prolonged periods, especially in older adults 1

Drug Interactions

• Take detailed medication histories including over-the-counter medications, as NSAIDs have considerable risk of drug-drug and drug-disease interactions (heart failure, hypertension, hepatic/renal disease) 1
• If the patient takes low-dose aspirin, consider other analgesics before adding NSAIDs, as there may be interactions with antiplatelet effects 1, 6

Additional Treatment Options

Intra-articular Corticosteroids

• Consider intra-articular corticosteroid injections (such as triamcinolone hexacetonide) for moderate-to-severe shoulder pain, especially with evidence of inflammation or joint effusion 1
• This approach is particularly useful when oral NSAIDs are contraindicated or ineffective 1

Opioid Analgesics

• Opioids may be considered only when acetaminophen, topical agents, and NSAIDs have failed or are contraindicated 1
• Use opioids cautiously given their side effect profile and addiction potential 1

Essential Non-Pharmacologic Core Treatments

Pharmacologic therapy must be combined with non-pharmacologic approaches for optimal outcomes:

• Exercise and physical activity focusing on local muscle strengthening and general aerobic fitness 1
• Weight loss interventions if the patient is overweight or obese 1, 5
• Patient education to counter misconceptions that OA is inevitably progressive 1, 5
• Local heat or cold applications for temporary symptom relief 1, 5
• Assistive devices and appropriate footwear with shock-absorbing properties 1, 5

Common Pitfalls to Avoid

• Never exceed 4000 mg daily of acetaminophen, and consider lower limits (3000 mg) in elderly patients 1, 2
• Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor) 1, 2
• Avoid prolonged NSAID use at high doses, particularly in elderly patients who are at highest risk for serious adverse events 1
• Do not use glucosamine or chondroitin products, as current evidence does not support their efficacy 1
• Never overlook non-pharmacologic treatments—they are not optional adjuncts but essential core therapy 1