Self-Care Options for Arthritis Therapy

W. Steven Pray, PhD, DPh; Joshua J. Pray, PharmD candidate

Disclosures

US Pharmacist. 2004;29(5) 

As the average age of the American population creeps slowly upward with the aging of the baby-boomer generation, conditions associated with aging will assume growing importance. One of these is arthritis, which affects as many as 70 million Americans.[1] Unfortunately, compared to unaffected patients, those with arthritis tend to be more sedentary, which leads to debilitating conditions such as obesity, heart disease, diabetes mellitus, and hypertension. Of course, obesity is also a causal factor for osteoarthritis.[2]

Fortunately, numerous self-care therapies are available to the public. Each has advantages and disadvantages, and judicious counseling from the pharmacist can assist patients greatly in choosing the most appropriate product.

Arthritis is not a self-diagnosable condition. When a patient asks for a product for arthritis, the pharmacist should question him or her closely to ascertain whether a physician has diagnosed the condition. Some patients wrongly self-diagnose the onset of arthritis. Careful questioning may reveal the correct etiology. For instance, a patient may have been relatively well until he or she undertook a new exercise regimen or lengthened the duration or intensity of an established routine. The pharmacist should explain the possibility of overuse syndrome and urge the patient to ease the regimen until the pain abates. The patient then may increase the intensity of the workout in a more gradual manner, as long as he or she remains pain-free.

If the patient does have a diagnosis of arthritis from a physician, the pharmacist should attempt to ascertain its type, since arthritis is a body of conditions with radically different etiologies, and the choice of self-care therapies is limited by the type of arthritis. The most common form of arthritis is osteoarthritis; other forms include rheumatoid arthritis, juvenile rheumatoid arthritis, psoriatic arthritis, and arthritis caused by gout or infections such as Lyme disease.

Nonprescription internal analgesics are all safe and effective for the pain of arthritis, if labeled directions are followed. NSAIDs such as aspirin, ibuprofen, naproxen sodium, and ketoprofen provide temporary relief of minor arthritis pain in adults, but they are not appropriate for children younger than 12 without a physician recommendation. Patients should understand that internal analgesics do not halt or modify the underlying disease. Although NSAIDs relieve pain, the underlying condition progresses. NSAIDs should not be used for more than 10 days. Each NSAID is labeled with numerous precautions, contraindications, and warnings. Patients must be urged to read the label carefully before using a product. Acetaminophen has a more enviable safety profile when compared to NSAIDs, but its efficacy is less than that of the NSAIDs.[3]

Various external analgesic products are used for arthritis. Products include warming ingredients such as methyl salicylate and cooling ingredients such as camphor or menthol. They do little to warm underlying tissues, giving the illusion of warmth mostly at the surface of the skin. They carry an odor that many patients find objectionable, and the ointments leave a greasy feel to the skin. Further, they must not be used with any form of thermotherapy (eg, heating pads), as concomitant use can cause burns. They should not be used for more than seven consecutive days.

Thermotherapy is the term used for heating modalities. Self-care heating methods include the ubiquitous heating pad, hot water bottles, paraffin wax baths, and the therapeutic heat wrap.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS; a subsection of NIH) stresses that heat can reduce the pain and inflammation of arthritis by increasing blood flow, maximizing the patient's tolerance for pain, and enhancing flexibility.[4] The agency also points out that heat application does not require a professional physical therapist but may be safely applied at home. The agency suggests that patients place warm towels or hot packs directly over an inflamed joint after taking a warm bath or shower. The labels of each specific heating device should be read carefully for arthritis-specific information. For instance, the therapeutic heat wrap is recommended for osteoarthritis, but the manufacturer suggests consulting with a physician before using it for rheumatoid arthritis.

Heating pads are widely thought of as safe but must be used carefully. Relief of arthritis pain may allow the patient to fall asleep, but the patient must take precautions against this, such as setting an alarm. The risk of burns rises if the patient sleeps while using a heating pad. On the other hand, the therapeutic heat wrap may be used while sleeping, since it produces safe, low-level heat therapy. Paraffin wax baths require a waiting period while the wax melts (as long as four hours) and immersion in wax that is 123°F to 131°F, and the manufacturers suggest periodic refilling with 6 lb of paraffin wax, which presents a financial problem for some patients. Further, if the patient immerses part of the body while the unit is melting the wax, burns might result.

NIAMS also advises patients that application of cold (known as cryotherapy) can help reduce the pain of arthritis by numbing the nerves surrounding the joint.[4] Cryotherapy reduces the inflammation of arthritis and minimizes muscle spasticity. Home methods of applying cryotherapy include using gel packs or homemade cold packs that contain ice or cold water in flexible bags. However, the patient should be urged to remove the cryotherapy device whenever the area is numb or in 20 minutes, whichever comes first.

Despite an overwhelming lack of reliable scientific evidence to prove their efficacy, alternative therapies remain popular for arthritis.[5] Osteoarthritis causes more patients to resort to alternative therapies than any other medical condition, partly because of frustration with existing modalities.[6] Glucosamine and chondroitin are among the most popular alternative therapies, having been the subjects of a popular book from the late 1990s.[7] Glucosamine is obtained from oyster and crab shells; chondroitin is derived from shark and cow cartilage.

Chondroitin has theoretical efficacy in arthritis partly because of its ability to serve as a component in the production of proteoglycans, compounds that improve viscoelastic and hydration properties within the joint and protect cartilage.[8] Chondroitin also exerts anti-inflammatory effects and inhibits extracellular proteases that metabolize connective tissues. The net effect of chondroitin is to control cartilage matrix integrity and bone mineralization, which is of theoretical use in degenerative articular disease. Although there is still a paucity of data to prove that proteoglycan substrate augmentation affects cartilage regeneration or repair, the ingredient is widely promoted for providing strength and resilience.[6]

Glucosamine is theoretically of use in arthritis due to its effect on cartilage cells. By increasing production of proteoglycans and glycosaminoglycans, glucosamine may yield an anti-inflammatory effect.[6] Supporters believe that glucosamine can regenerate articular cartilage.

MEDLINE searches on both glucosamine and chondroitin (including arthritis as a secondary keyword) demonstrate that there is little evidence to support their use in arthritis. However, one study showed positive results for the combination. In a placebo-controlled double-blind trial, investigators gave the combination to 34 US Navy men for 16 weeks.[9] All had chronic pain and degenerative joint disease of the knee or lower back confirmed by x-rays. There was a significant improvement in knee arthritis, as measured by patient assessments and physical examinations; there was no discernible benefit for the lower back. Glucosamine and chondroitin combined are not proven to have any synergistic effect over either ingredient given alone.[6] However, the ingredients are free of serious adverse reactions, so there is little risk in using them.

The efficacy of glucosamine and chondroitin is of sufficient lay interest that NIAMS has funded a study to explore their efficacy. Known as GAIT (Glucosamine/ Chondroitin Arthritis Intervention Trial), the placebo-controlled study will measure their effect in reducing pain and improving functional ability in patients with osteoarthritis of the knee.[10] Results are not yet available.

Emu oil is the main ingredient of blue ointment. The efficacy and safety of emu oil are not yet proven. Some products add menthol, which may exert a cooling or warming effect that the patient interprets as relief of arthritis pain. They may also contain aloe vera, methylsulfonylmethane and other ingredients of unknown safety and efficacy. The Web sites that tout these products are predictably long on customer testimonials but notably lacking in the elements of the scientific method that would allow interested readers to impartially assess their supposed effects in arthritis.

SAM-e (S-adenosylmethionine) is another dietary supplement sold for arthritis. It donates methyl groups, which are believed by supporters to assist in proteoglycan production. Studies are sparse, and most suffer from crippling flaws, such as lack of randomization and/or blinding, missing controls, and flawed statistics.[6] SAM-e has caused gastrointestinal disturbances such as diarrhea.

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