Arthritis Health Center

Arthritis Treatment: Kick It Up a Notch

March 26, 2002 -- When it comes to treating arthritis pain, it is important to "hit early, hit hard," say experts at the American Pain Society. New guidelines call for more aggressive treatment of arthritis pain and earlier use of surgery for those who get no relief from drugs.

The guidelines state that a group of anti-inflammatory drugs called Cox-2 inhibitors, such as Celebrex, Vioxx, and Bextra, be the first method of treatment for moderate to severe long-term pain.

The new guidelines also call for use of narcotic pain killers. These narcotics are recommended for people with severe, long-term pain that does not respond to other drugs.

Arthritis Foundation medical director John Klippel, MD, says the guidelines are needed because many doctors still do not adequately treat arthritis pain.

Some 21 million Americans suffer from osteoarthritis, a painful deterioration of the cartilage that cushions the body's joints. That figure is expected to rise to about 30 million in less than 20 years, as baby boomers reach their 60s and beyond. An additional 2.1 million people have rheumatoid arthritis, an inflammatory disease in which the immune system attacks the joints.

Many doctors continue to recommend older anti-inflammatory drugs even though the potential side effects of long-term use, including stomach ulcers and bleeding, can be life threatening, Klippel tells WebMD. The Cox-2 inhibitors, introduced in 1999, are believed to cause fewer stomach problems. But traditional anti-inflammatory drugs are still widely used, primarily because they are cheaper.

The American Pain Society (APS) guidelines state that these traditional anti-inflammatory drugs should be used only if Cox-2 drugs and acetaminophen (Tylenol) prove ineffective, or if they are given along with medications to minimize stomach and intestinal problems.

Other recommendations from the APS panel include:

• All treatment for arthritis should begin with a comprehensive assessment of pain and function, and mild-to-moderate pain should be managed with acetaminophen.
• Most people with arthritis, including the obese and elderly, should be considered for surgical treatment when drug therapy is no longer effective. To maximize the benefits of joint-replacement surgery, the panel recommends that it be performed before severe deformity and muscular degeneration occur.
• Narcotic pain killers, such as oxycodone (OxyContin) and morphine, are recommended for the treatment of severe arthritis pain that cannot be relieved with Cox-2 inhibitors and traditional anti-inflammatory drugs.

"I think there has been a general reservation about using narcotics because of their addictive potential," Klippel says. "But we have come to learn that reasonable use of narcotics doesn't pose a risk of addiction in this setting. They effectively treat pain for many people and improve their quality of life."

In addition to issuing specific treatment recommendations, the APS panel outlined steps arthritis patients can take to improve their quality of life. They include maintaining an ideal body weight and getting appropriate exercise. The panel called on doctors to refer patients for physical and/or occupational therapy.

"Since arthritis is a long-term and progressive disease, doctors must be sure that regular exercise or physical therapy are important components of a comprehensive management program," panel chairperson Ada Jacox, PhD, says. "Staying active is a critical component for managing this disease."-->