To reduce pain and inflammation in mild cases of rheumatoid arthritis and osteoarthritis, your doctor will probably prescribe aspirin or another nonsteroidal anti-inflammatory drug (NSAID), such as naproxen or ibuprofen. Your doctor may also suggest acetaminophen.

In more advanced cases, your doctor may recommend corticosteroid joint injections -- strong anti-inflammatories -- to ease the pain and stiffness of affected joints. Depending on the individual, results range from temporary relief to long-lasting suppression of symptoms. Doctors are also using hyaluronate gel-like solutions in joint injections to further restore the cushioning and lubricating properties of normal joint fluid, thereby minimizing pain. Some examples are Hyalgan, Synvisc, Supartz, and Orthovisc.

Osteoarthritis

A variety of medications are available to treat osteoarthritis pain, including:

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). These are among the most common treatments for osteoarthritis pain.� Purchased over-the-counter or by prescription, NSAIDs ¡ª such as aspirin, ibuprofen (Advil or Motrin) and diclofenac (Cataflam, Voltaren) ¡ª act quickly to relieve pain. There are more than 30 drugs classified as NSAIDs and each has a slightly different chemical structure, is metabolized differently and seems to work differently among patients. (Other drugs, such as methotrexate, chloroquine, pencillamine and gold salts, work through the immune system and have some anti-inflammatory effects.) For severe osteoarthritis pain, the NSAID ketorolac (Toradol) can be given as an injection for speedy, although brief, pain relief.

Oral Tramadol (Ultram). Available for moderate to severe pain.�

Comments: When introduced to the United States in 1966, the U.S. Food and Drug Administration classified tramadol as a non-narcotic drug. However, some cases of addiction have been reported. Tramadol also has been linked to seizures in susceptible individuals, especially when the drug is given at high doses.� The risk of seizure is higher in patients who are also taking antidepressant drugs such as desipramine (Norpramine) or doxepin (Sinequan).� Caution also has been advised with well-known antidepressants fluoxetine hydrochloride (Prozac), sertraline hydrochloride (Zoloft) and paroxetine (Paxil). 

Narcotic Drugs - Opioids. When pain is extreme, narcotic drugs derived from opium may be prescribed. For arthritis, the most common narcotics prescribed are propoxyphine (Darvon), codeine (Tylenol #3 or #4) or hydrocodone (Vicodin and Lorcet), although oxycodone (Percodan and Percocet) is being prescribed more often now.� These narcotic drugs bring swift pain relief, allowing the patient more activity during the day and better sleep at night.

Comments: Opioids can have side effects and may lead to dependency, but rarely addiction.� Prescribing them should be done only when more conservative treatment has failed, and a patient understands the risks and rewards involved in their use. Opioids are being used more often in advanced arthritis. (See the Arthritis Library for more information about opioids.)

Mixed Agonists/Antagonists (Synthetic Narcotics). This class of drugs is used at times for arthritis pain.� They include pentazocine (Talwin-NX or Talace), nalbuphine (Nubain), butorphanol (Stadol or Stadol NS) and buprenorphine (Buprenex). Only pentazocine is available in oral form and likely to be useful on in some cases of advanced arthritis.�

Comments: This group of drugs has what is called a "low ceiling effect," meaning a small dose may be helpful, but more can cause complications. They also cannot be mixed with strong natural opioids.

Viscosupplements. Two agents have been approved by the FDA for osteoarthritis of the knee.� They are injected into the knee to replace the hyaluronic acid, a substance that gives the knee joint viscosity, and which appears to break down in osteoarthritis.

The two viscosupplements currently on the market are Hyalgan and Synvisc.� For Hyalgan, five injections over 6-10 weeks are needed, and for Synvisc, only three injections are needed.

Glucosamine sulfate. One of the most exciting recent developments in arthritis treatment, glucosamine has been shown to relieve pain and potentially rebuild damaged cartilage. Available without a prescription, glucosamine is found in high concentrations in seashells, from which glucosamine is harvested. Glucosamines are used by the body to manufacture proteoglycans, substances that hold collagen threads together. Collagen is an element of cartilage.� Some studies have shown that glucosamine sulfate actually "feeds" the joints and stimulates regrowth at the cellular level.� Glucosamine sulfate also matches NSAIDs in providing long-lasting pain relief, researchers have found ¡ª and without NSAIDs' side effects.

A powdered form of glucosamine sulfate, which can be mixed into juice, is expected to be available soon.� Glucosamine sulfate is used to treat patients of all ages and all stages of osteoarthritis.

Rheumatoid Arthritis

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). These are among the most common treatments for osteoarthritis pain.� Purchased over-the-counter or by prescription, NSAIDs ¡ª such as aspirin, ibuprofen (Advil or Motrin) and diclofenac (Cataflam, Voltaren) ¡ª act quickly to relieve pain. There are more than 30 drugs classified as NSAIDs and each has a slightly different chemical structure, is metabolized differently and seems to work differently among patients. (Other drugs, such as methotrexate, chloroquine, pencillamine and gold salts, work through the immune system and have some anti-inflammatory effects.)� For severe rheumatoid arthritis pain, the NSAID ketorolac (Toradol) can be given as an injection for speedy, although brief, pain relief.

Non-NSAIDs. Pain relievers that are NOT anti-inflammatories ¡ª such as acetaminophen (Tylenol), aspirin plus oxycodone (Percodan), propoxyphene (Darvon), pentazocine (Talwin), meperidine hydrochloride (Demerol) and codeine ¡ª can actually cause damage in rheumatoid arthritis patients. If pain is suppressed, but inflammation isn't, movement can worsen the inflammation by releasing more of the enzymes that damage bones and ligaments.�

Glucosamine sulfate. This over-the-counter supplement is found in high concentrations in seashells, from which glucosamine is harvested. While glucosamine has been shown to relieve pain and possibly rebuild cartilage in the joints of osteoarthritis patients, it does not appear to have the same pain-relieving effect for rheumatoid patients. Still, some doctors recommend that rheumatoid patients take a standard dose of glucosamine sulfate ¡ª three 500-milligram capsules daily ¨C because it may help prevent some of RA's degenerative effects.

Cortisone. The most powerful anti-inflammatory drugs are the cortisone-type drugs, or corticosteroids. They can be lifesavers when given for asthma attacks or an adrenal crisis.� They may provide complete pain relief when given in high doses on a short-term basis for patients with rheumatoid arthritis flare-ups or when injected into a painful, red-hot, swollen joint. Doctors try to avoid side effects by giving as low a dose as possible and injecting the drugs only at the site of the inflammation.

Comments: Corticosteroids should be considered a last resort treatment. Their side effects from long-term use include osteoporosis (brittle bones), cataracts, glaucoma, high blood pressure, stomach bleeding or irritation, weight gain, frequent infections and worsening of diabetes mellitus. 

Antibiotics.� Doctors sometimes find there is a bacterial component in some kinds of inflammatory arthritis, which can be treated by antibiotics.�

Comments: Because antibiotics can throw off the body's natural balance, it is recommended that patients also take prebiotic supplements, such as insulin, fructoolegosacchrides� (FOS), take probiotics, or eat organic yogurt with various friendly bacterial cultures.

Biologic Response Modifiers (BRMs). These substances target specific parts of the immune system, but leave other parts alone.� For rheumatoid arthritis, the BRM etanercept interferes with a chemical called TNF, which is believed to play a major role in inflammation and joint damage. Another biologic agent, infliximab, blocks TNF through another pathway and has been approved for use in rheumatoid arthritis and Crohn's disease. Oral proteolytic enzymes also are considered biologic response modifiers; they act like biological "vacuum cleaners" to rid the body of harmful proteins that can lodge in the joints.  

Disease-Modifying Anti-Rheumatic Drugs (DMARDs). These agents are used primarily to treat rheumatoid arthritis, but also help people with ankylosing spondylitis, psoriatic arthritis and a few other arthritis-related diseases. DMARDs can slow the advance of disease.� The group includes leflunomide and cyclosporine (originally developed to prevent organ transplant rejection).

Narcotic Drugs - Opioids. When pain is extreme, narcotic drugs derived from opium may be prescribed. For arthritis, the most common narcotics prescribed are propoxyphine (Darvon), codeine (Tylenol #3 or #4) or hydrocodone (Vicodin and Lorcet), although oxycodone (Percodan and Percocet) is being prescribed more often now.� These opioids bring swift pain relief, allowing the patient more activity during the day and better sleep at night. (See the Arthritis Library for more information about opioid drugs.)

Comments: Opioids can have side effects and may lead to dependency, but rarely addiction.� Prescribing them should be done only when more conservative treatment has failed, and a patient understands the risks and rewards involved in their use. Opioids are being used more often in advanced arthritis. (See the Arthritis Library for more information about opioids.)

Mixed Agonists/Antagonists (Synthetic Narcotics). This class of drugs is used at times for arthritis pain.� They include pentazocine (Talwin-NX or Talacen), nalbuphine (Nubain), butorphanol (Stadol or Stadol NS) and buprenorphine (Buprenex). Only pentazocine is available in oral form and likely to be useful on in some cases of advanced arthritis.�

Comments: This group of drugs has what is called a "low ceiling effect," meaning a small dose may be helpful, but more can cause complications. They also cannot be mixed with strong natural narcotic drugs.

Ankylosing Spondylitis

Early diagnosis and treatment of this condition is critical to controlling pain and stiffness, and perhaps plays a part in preventing the bones in the neck and back from fusing. In women, ankylosing spondylitis (AS), or spinal arthritis, often is mild and difficult to diagnose.� Treatment is tailored to the individual.

Disease-Modifying Anti-Rheumatic Drugs (DMARDs), or Slow-Acting Anti-Rheumatic Drugs (SAARDs).� While these agents typically are used more frequently to treat other forms of arthritis, they can provide relief.� However, they may take several months to become effective.� The group includes leflunomide, sulfasalazine and cyclosporine (originally developed to prevent organ transplant rejection).  

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). More than 30 drugs are classified as NSAIDs, which can help relieve pain and stiffness, but do not affect the advance of ankylosing spondylitis.� NSAIDs include over-the-counter drugs such as ibuprofen.� Each NSAID has a slightly different chemical structure, is metabolized differently, and seems to work differently among individual patients. For severe AS pain, the NSAID Ketorolac (Torodol) can be given as an injection for speedy, although brief, pain relief.

Oral Tramadol (Ultram). Available for moderate to severe pain.

Comments: When introduced to the United States in 1966, the U.S. Food and Drug Administration classified tramadol as a non-narcotic drug. However, some cases of addiction have been reported. Tramadol also has been linked to seizures in susceptible individuals, especially when the drug is given at high doses. The risk of seizure is higher in patients who are also taking antidepressant drugs such as Norpramine or Sinequen).� Caution also has been advised with well-known anti-depressants fluoxetine hydrochloride (Prozac), sertraline hydrochloride (Zoloft) and paroxetine (Paxil).

Narcotic Drugs. �When pain is extreme, narcotic drugs, derived from opium, may be prescribed. For arthritis, the most common narcotics prescribed are propoxyphine (Darvon), codeine (Tylenol #3 or #4) or hydrocodone (Vicodin and Lorcet), although oxycodone (Percodan and Percocet) is being prescribed more often now.� These narcotic drugs bring swift pain relief, allowing the patient more activity during the day and better sleep at night. They are being used more often in inflammatory forms of the disease such as ankylosing spondylitis.

Comments: Opioids can have side effects and may lead to dependency, but rarely addiction.� Prescribing them should be done only when more conservative treatment has failed, and a patient understands the risks and rewards involved in their use. Opioids are being used more often in advanced arthritis. (See the Arthritis Library for more information about opioids.)