Treatments for arthritis pain vary in terms of type, effectiveness, and mode of administration. Types of therapies include oral analgesics, topical analgesics, oral non-steroidal anti-inflammatory drugs (NSAIDS), topical NSAIDS, oral narcotics, and parenteral (meaning intramuscular or intravenous) narcotics.

As a general rule, for mild to moderate pain, narcotics should not be used. What this means is that the non-narcotic analgesics or NSAIDS are the drugs of choice.

The next decision to be made is, “Do I use an oral drug or will a topical agent, a rub, work just as well?”

So how does a patient choose?

One significant measure is efficacy. Does the agent really work?

The perception among many patients as well as physicians is that topical agents may not be as effective as oral drugs.

A recent study looked at this issue of effectiveness and patient preference in regards to oral versus topical NSAIDS.

Their conclusion? “In older patients with knee osteoarthritis, treatment with either oral or topical non-steroidal anti-inflammatory drugs (NSAIDs) had an equal effect on knee pain after one year,” according to the results of this randomized controlled trial reported in the British Medical Journal.

The study was conducted among patients from 26 general practices in the United Kingdom.

Patients eligible for study participation were over the age of 50 and had a history of knee pain on most days of the month for at least 3 months. All participants had been treated for knee pain in the 3 years before study enrollment. Patients with a history of peptic ulcer, significant indigestion, or kidney problems were excluded from study participation.

There were 2 treatment groups. In 1 group, patients were randomized to receive a recommendation for either topical or oral ibuprofen, at a dose determined by the patient. In the other intervention group, patient volunteers were left to decide for themselves whether they used topical or oral ibuprofen.

The volunteers were observed for 24 months. The primary outcome measure was the WOMAC Osteoarthritis Index questionnaire, which was used to assess knee pain and stiffness at 1 year. The WOMAC (Western Ontario McMaster) scale is typically used in arthritis studies to assess quality of life issues.

282 patients were included in the randomized trial and 303 patients participated in the patient preference study. The average age of the volunteers was 64 years, and baseline characteristics were similar regardless of study treatment. The mean global score on the WOMAC at baseline was 40 of a possible 100.

224 subjects in the preference study opted for topical treatment, whereas 79 chose oral ibuprofen. Patients with more severe or widespread pain generally selected oral therapy.

There was a modest change in WOMAC scores at 1 year, regardless of study therapy. WOMAC pain scores at 24 months slightly favored oral therapy, but this difference was not considered significant.

More patients in the topical ibuprofen group experienced significant pain at 3 months, which prompted 11% of the volunteers receiving topical treatment to change to oral ibuprofen.

Quality-of-life scores were similar between the oral and topical ibuprofen groups.

There were no differences in the rate of major side effects in the topical and oral ibuprofen groups. However, oral ibuprofen was associated with side effects involving the respiratory tract in 17% of participants compared to only 7% of subjects receiving topical ibuprofen. In addition, signs of kidney malfunction occurred more frequently in the oral ibuprofen treated patients.

Rates of changing treatment because of adverse effects were 1% and 16% in the topical and oral ibuprofen groups, respectively.

The conclusions were:

Patients with knee pain consider topical NSAIDs effective for mild pain but reserve oral NSAIDs for more severe or persistent pain. Patients generally believe that topical NSAIDs do not have adverse effects, but they will tolerate mild adverse effects associated with oral NSAIDs.

The current study suggests that topical NSAIDs are similarly effective to oral NSAIDs for knee pain for 1 year, and oral NSAIDs are associated with a higher rate of adverse effects.

Dr. Martin Underwood, who was the spokesperson for the research group conducting the study stated, “If topical NSAIDs are as effective as oral NSAIDs for reducing knee pain but produce fewer adverse effects, then topical treatment might be preferred.”

In our practice, we have found that topical agents are generally useful for patients with mild to moderate localized pain. However, if a patient has generalized pain, it makes no sense for them to slather a goo all over themselves.

A big bugaboo though with oral NSAIDS are the potential side effects, particularly in older patients.

One area not explored in the study was the use of pain patches. Lidoderm, which is a patch containing lidocaine, has been found to be helpful for some patients with arthritis, although an FDA approval has not yet been secured for this indication.

Newer NSAID patches containing diclofenac will also be available soon and these look very promising for local arthritis-related pain.

As far as topical agents that don’t contain NSAID, my favorite is Myorx which contains Omega-3 fatty acids. This helps provide anti-inflammatory effect without the potential problems associated with NSAIDS. For more information about Myorx, you can visit http://www.aocm.org or call the Arthritis and Osteoporosis Center of Maryland at (301) 694-5800.



Butalbital apap caffeine