Best Medicine for Bone-on-Bone Arthritis Pain
Start with acetaminophen (paracetamol) at regular doses up to 4000 mg daily as your first-line medication for bone-on-bone osteoarthritis pain, and only escalate to NSAIDs if acetaminophen provides insufficient relief. 1
First-Line Treatment: Acetaminophen
Acetaminophen should be your initial pharmacologic choice because it provides comparable pain relief to NSAIDs for mild-to-moderate osteoarthritis pain while having a significantly superior safety profile, particularly regarding gastrointestinal, renal, and cardiovascular risks. 1, 2, 3
Use regular scheduled dosing rather than "as needed" to maintain consistent pain control for chronic arthritis pain. 4
The maximum daily dose is 4000 mg, though consider limiting to 3000 mg daily in elderly patients (over 65 years) to enhance safety and reduce hepatotoxicity risk. 4, 5
Acetaminophen is the most cost-effective option for osteoarthritis pain management. 1
Second-Line Treatment: Topical NSAIDs
If acetaminophen fails to provide adequate relief, apply topical NSAIDs (such as diclofenac gel) before considering oral NSAIDs because they provide localized pain relief with minimal systemic absorption and substantially lower risk of gastrointestinal, renal, and cardiovascular complications. 4, 5
Topical capsaicin is an alternative localized agent that may provide additional pain relief. 1, 5
Third-Line Treatment: Oral NSAIDs
Only prescribe oral NSAIDs (such as ibuprofen) when both acetaminophen and topical treatments have failed, and use them at the lowest effective dose for the shortest possible duration. 1, 4
NSAIDs are modestly more effective than acetaminophen for pain reduction (the average patient on NSAIDs has less pain than 64% of patients on simple analgesia), but this small benefit must be weighed against significantly higher risks. 1, 6
Always co-prescribe a proton pump inhibitor alongside any oral NSAID for gastroprotection, as NSAIDs can cause ulcers and bleeding in the stomach and intestines at any time during treatment, potentially without warning symptoms. 4, 7
Critical Safety Considerations
Elderly patients face substantially higher risks with NSAIDs, including gastrointestinal bleeding, renal insufficiency, platelet dysfunction, and cardiovascular complications. 1, 5
NSAIDs should be avoided entirely in patients with chronic kidney disease stage 4 or higher due to risk of further renal deterioration, fluid retention, and hypertension. 8
The FDA warns that NSAIDs increase the chance of heart attack or stroke, which can lead to death, and this risk increases with longer use, higher doses, and pre-existing heart disease. 7
Special Considerations for Severe "Bone-on-Bone" Disease
For patients with severe bone-on-bone arthritis who have failed acetaminophen, topical agents, and oral NSAIDs, consider intraarticular corticosteroid injections for acute pain flares, especially when there is evidence of inflammation and joint effusion. 1
Intraarticular hyaluronic acid preparations may provide longer-lasting pain relief (compared to corticosteroids) for severe knee osteoarthritis not adequately controlled with oral medications. 1
For severe refractory pain, opioids may be considered with extreme caution, with fentanyl and buprenorphine having the safest pharmacokinetic profiles, particularly in patients with kidney disease. 8
Essential Non-Pharmacologic Core Treatments
Physical activity and exercise programs focusing on local muscle strengthening and general aerobic fitness must accompany any pharmacologic management, as they are core evidence-based treatments that reduce pain and improve function. 1, 4, 5
Weight loss is essential if the patient is overweight or obese, as reducing joint load directly decreases pain. 1, 4, 5
Local heat or cold applications and assistive devices can provide significant relief without medication risks. 8, 5
Common Pitfalls to Avoid
Never exceed 4000 mg daily of acetaminophen (and strongly consider 3000 mg maximum in elderly patients) to prevent hepatotoxicity. 4, 5
Never prescribe oral NSAIDs without gastroprotection (proton pump inhibitor co-prescription). 4, 5
Avoid prolonged NSAID use at high doses, particularly in elderly patients who are at highest risk for serious adverse events including GI bleeding, renal failure, and cardiovascular complications. 1, 4, 5
Do not use glucosamine or chondroitin products, as current evidence does not support their efficacy for osteoarthritis despite their popularity. 4
Topical NSAIDs cannot be recommended as evidence-based treatment according to older guidelines, though more recent evidence suggests they may have a role as second-line therapy. 1