What’s The Story on NSAIDs for Arthritis Pain?

Use of an NSAID (nonsteroidal anti-inflammatory drug) is standard medical practice for osteoarthritis (as well as other orthopedic problems). For people over the age of 65, the prevalence of NSAID use is close to 96%.^[1]Pilotto, A., Franceschi, M., Leandro, G., Di Mario, F., & Geriatric Gastroenterology Study, G. (2003). NSAID and aspirin use by the elderly in general practice: effect on gastrointestinal … Continue reading

An NSAID is a drug that does three things: reduces inflammation, pain, and swelling – the body’s natural response to injury. It’s often the first thing we reach for when something hurts – Advil, Motrin, Aleve, Bayer, Excedrin among others. I have on a number of occasions. These drugs are available over-the-counter meaning you don’t need a prescription from a doctor to purchase them.

Because many NSAIDs are sold over-the-counter (OTC) and pharmacy companies run TV ads portraying them as the thing to do to keep active, people tend to think the drugs are safe and not a big deal to take whenever they feel like it or for as long as they want. In fact, sometimes people take an NSAID before they engage in some activity like running, tennis, a hike, skiing to reduce or prevent pain and swelling.

In addition to OTC NSAIDs, there are prescription NSAID drugs that include Celebrex, Mobic, Voltaren, Relafen and several others. These drugs tend to be more powerful than the OTC options.

Why so many?

Different people will have different reactions to the same drug. If you and I have an ankle sprain, maybe Celebrex is effective for me while not effective for you. This variability is due to how a person’s body absorbs, distributes, metabolizes and eliminates the drug and how the drug affects certain enzymes in the inflammatory process.^[2]https://onlinelibrary.wiley.com/doi/full/10.1111/bcpt.12117

But these drugs are not without significant risks and you have to consider these risks carefully before taking an NSAID.

The risks that are talked about the most are:

1. Gastrointestinal bleeding
2. Myocardial infarction
3. Stroke
4. Kidney damage

But there’s another risk of taking NSAIDs that is rarely discussed and one, for people with symptomatic osteoarthritis, should know about and understand.

NSAID use can weaken joint cartilage.

There’s some evidence that shows NSAIDs taken at therapeutic doses interfere with the production of glycosaminoglycan.^[3]Shield MJ. Anti-inflammatory drugs and their effects on cartilage synthesis and renal function. Eur J Rheumatol Inflamm. 1993;13(1):7-16. Review. PubMed PMID: 7821339.

Why should you care about that? What’s a glycosaminoglycan (GAG) anyway?

A GAG is a family of carbohydrates that attracts and holds water which, in turn, helps your joint cartilage act as a kind of shock absorber and improves lubrication of the joint.

Less GAG means less water -> less lubrication -> less shock aborption -> more dysfunction and pain.

Of course, the reason most people turn to an NSAID is for pain relief. And the downside to this is that pain relief can increase joint loading. One researcher said, “Of particular concern is the fact that anti-inflammatory or analgesic relief may actually be associated with an increase in joint forces.”^[4]Schnitzer T, et al. Effect of NSAIDs on knee loading in patients with osteoarthritis. Arthritis Rheum. 1990;33:S92-S97.^[5]Schnitzer T, et al. Effect of piroxicam on gait in patients with osteoarthritis of the knee. Arthritis Rheum. 1993;36:1207-1213.

The International Cartilage Repair Society and Osteoarthritis Research Society International has stated that NSAID use should be limited to the short term. “In patients with symptomatic hip or knee osteoarthritis, non-steroidal anti-inflammatory drugs (NSAIDs) should be used at the lowest effective dose but their long-term use should be avoided if possible.” They added that NSAIDs should not be first-line therapy for joint OA.^[6]Zhang W, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis and Cartilage. 2008;16:137-162.

What do you do?

There are some supplements that appear to both reduce pain and not run the risk of weakening your joint cartilage.

1. Chondroitin Sulfate has been shown to be more effective than Celecoxib in patients with knee oasteoarthritis^[7]Pelletier, J. P., Raynauld, J. P., Beaulieu, A. D., Bessette, L., Morin, F., de Brum-Fernandes, A. J., . . . Martel-Pelletier, J. (2016). Chondroitin sulfate efficacy versus celecoxib on knee … Continue reading ^[8]Hochberg, M. C., Martel-Pelletier, J., Monfort, J., Moller, I., Castillo, J. R., Arden, N., . . . Group, M. I. (2016). Combined chondroitin sulfate and glucosamine for painful knee osteoarthritis: a … Continue reading
2. Curcumin has been shown to be effective at reducing pain and aid in controlling the inflammation process.^[9]Chin, K. Y. (2016). The spice for joint inflammation: anti-inflammatory role of curcumin in treating osteoarthritis. Drug Des Devel Ther, 10, 3029-3042. doi:10.2147/DDDT.S117432

Bottom line, avoid taking NSAIDs if you can. Sometimes, well, you just have to but do your best to limit the dosage and duration.

Thanks for reading.

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