Arthritis medications

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Pain is our oldest friends from the beginning our lives.  A wide range of remedies are available from the very beginning of civilization.When we are talking about arthritis tons of arthritis remedies are available. Now a days many medications are widely used. Arthritis medications are listed below.


Paracetamol (1 g up to 4 times daily) is the oral analgesic of first choice. If successful, the preferred long ­term oral analgesic. It is an over the counter (OTC) drug It inhibits prostaglandin synthesis in the brain but has less effect on peripheral prostaglandin production. It is generally well tolerated and has few adverse effects and drug interactions. There is a possible  increased  risk  of  both  gastrointestinal  events  and  cardiovascular disease with chronic usage, but it is uncertain  whether  this  is  due  to  the  underlying  disease  or the  drug  itself. If  paracetamol  fails  to  achieve  an  adequate  response,  it  can  be  used  in  combination  with opioids  such  as  codeine  and  dihydrocodeine  in  compound analgesic preparations like co­codamol (codeine and paracetamol) or co­dydramol (dihydrocodeine and  paracetamol).  Although  these  are  more  effective  than  paracetamol, side­effects include constipation, headache and  confusion,  especially  in  the  elderly.  The  centrally acting  analgesics  tramadol  and  meptazinol  may  be useful  for  temporary  control  of  severe  pain  unresponsive to other measures. Both may cause nausea, bowel upset, dizziness and somnolence,  and  withdrawal symptoms  after  chronic  use.  The  non­opioid  analgesic nefopam  (30–90 mg  3 times  daily)  can  help  moderate pain,  though  side­effects  (nausea,  anxiety,  dry  mouth) often  limit  its  use. Patients with severe  or  intractable pain may require stronger opioid analgesics such as oxy-codon and morphine.

Non-steroidal anti-inflammatory drugs

These are among the most widely used drugs. Oral NSAIDs are particularly useful in the management of  pain  that  has  an  inflammatory  component,  and  a long acting  NSAID  taken  in  the  evening  may  help reduce  early  morning  stiffness.  There  is  marked  variability  in  individual  tolerance  and  response;  patients who  do  not  respond  to  one  NSAID  may  still  gain relief  from  another.  The  mechanism  of  NSAID  action is  through  inhibition  of  prostaglandin  H  synthase  and cyclo­oxygenase (COX) enzymes. Arachidonic acid, derived from membrane phospholipids, is metabolised to produce prostaglandins and leukotrienes by the COX and 5­lipoxygenase pathways respectively. There are two isoforms  of  COX,  encoded  by  different  genes. COX­1 is constitutively expressed and fulfils  a ‘housekeeping’ function in the gastric mucosa, platelets  and kidneys. The COX­2 enzyme is largely induced at sites  of  inflammation,  producing  prostaglandins  that cause  local  pain  and  inflammation,  but  COX­2  is  also up­regulated  in  the  CNS,  where  it  plays  a  role  in the  central  mediation  of  pain  and  fever.  Traditional NSAIDs,  such  as  ibuprofen,  diclofenac  and  naproxen, inhibit  both  COX  enzymes,  whereas  newer  NSAIDs, such  as  celecoxib  and  etoricoxib,  selectively  inhibit  COX­2.In  the  UK,  National  Institute  for  Health and Clinical Excellence (NICE) guidelines advise that a proton  pump  inhibitor  (PPI)  should  be  co­prescribed with  all  NSAIDs,  including  COX­2  selective  NSAIDs, even though  the  risk  of  gastrointestinal  events  with  these  is  low.  Since  chronic  PPI  therapy  is  associated  with  an  increased  risk  of  hip  fracture,  the  merits  of giving  PPI  therapy  with  a  COX­2  selective  drug  need to be weighed up carefully.Other  side­effects  of  NSAID  include  fluid  retention and renal impairment due to inhibition of renal prostaglandin  production,  non­ulcer associated  dyspepsia, abdominal  pain  and  altered  bowel  habit,  and  rashes.

Commonly used NSAIDs and their relative risk of gastrointestinal bleeding and perforation:

  • Very low risk(Selective COX-2 inhibitor)

Celecoxib- dose 100–200 mg

Etoricoxib-dose 60–120 mg inhibitor

  • Low risk(Weak anti inflammatory effect )

Ibuprofen-dose 600–1600 mg

Etodolac- dose 600 mg

Meloxicam-dose 7.5–15 mg

Nabumetone-dose 1–2 g

  • Medium risk

Ibuprofen-dose 1600–2400 mg

Naproxen-dose 500–1000 mg

Diclofenac-dose 75–150 mg

  • High risk

Indometacin-dose 50–200 mg( High incidence of dyspepsia and CNS side-effects like headache, dizziness, confusion)

Ketoprofen-dose 100–200 mg

  • Highest risk(Restricted use in those >60 yrs)

Piroxicam-dose 20–30 mg

Azapropazone-dose 600–200 mg (Uricosuric action)

Risk factors for NSAID-induced ulcers

  • Age >60 yrs
  • Past history of peptic ulcer
  • Past history of adverse event with NSAID
  • Concomitant corticosteroid use
  • High-dose or multiple NSAID
  • High-risk NSAID

Recommendations for the use of NSAID

  • Use with caution in patients with cardiovascular disease
  • Use the lowest dose for the shortest time possible to control symptoms
  • Avoid NSAID in patients on warfarin
  • Allow 2–3 weeks to assess efficacy. If response is inadequate, consider trial of another NSAID
  • Never prescribe more than one NSAID at a time
  • Co-prescribe proton pump inhibitor for patients with risk factors for gastrointestinal adverse effects

Topical agents (arthritis medications creams)

Topical  NSAID  creams  and  gels  and  capsaicin  (chilli extract; 0.025%) cream can help in the relieve of arthritis pain affecting  hands, elbows and knees.

Disease-modifying anti-rheumatic drugs (DMARDs)
When all measure fails to control pain these agents are used. These also prevent the complications and deformities. Here are some commonly used DMARDs.

Hydroxychloroquine: Unknown mechanism

Side effect: Rash, nausea, diarrhoea, headache, corneal deposits, retinopathy (rare)

Monitoring: Visual acuity, Amsler chart, fundoscopy6–12-monthly

Cyclophosphamide : Inhibits DNA synthesis and cell division

Side effect: Nausea, GI upset, alopecia, cystitis, myelosuppression, azoospermia, anovulation

Monitoring:FBC, urine (blood) Each i.v. injection

Ciclosporin : Inhibits DNA synthesis and cell division

Side effect: Nausea, GI upset, renal impairment, hypertension

Monitoring:FBC, LFTs, creatinine, blood pressure2–4-weekly

mycophenolate mofetil: Inhibits DNA synthesis and cell division

Side effect: Myelosuppression, GI upset (diarrhoea, vomiting, ulceration), hepatitis

Monitoring:FBC, LFTs Initially weekly, then monthly in first year, then every 3 months

Methotrexate: Inhibits DNA synthesis and cell division

Side effect: GI upset, stomatitis, rash, alopecia, hepatotoxicity, acute pneumonitis

Monitoring: FBC, LFTs Initially monthly, then every 3 months

Sulfasalazine : Unknown mechanism

Side effect: Nausea, GI upset, rash, hepatitis, neutropenia, pancytopenia (rare)

Monitoring: FBC, LFTs Monthly for 3 months, then 3-monthly

Hydroxychloroquine: Unknown mechanism

Side effect: Rash, nausea, diarrhoea, headache, corneal deposits, retinopathy (rare)

Monitoring:Visual acuity, fundoscopy12-monthly

Leflunomide: Blocks T-cell division

Side effect: Nausea, GI upset, rash, alopecia, hepatitis, hypertension

Monitoring:FBC, LFTs, BP 2–4-weekly

D-Penicillamine: Unknown mechanism

Side effect: Rash, stomatitis, metallic taste, proteinuria, thrombocytopenia

Monitoring: FBC, urine (for protein) Initially 1–2-weekly; 4–6-weekly for  maintenance

Gold: Unknown mechanism

Side effect: Rash, stomatitis, alopecia, proteinuria, thrombocytopenia, myelosuppression

Monitoring: FBC, urine (protein) after each injection

Ciclosporin: Blocks T-cell activation

Side effect: Nausea, GI upset, renal impairment, hypertension

Monitoring: FBC, LFTs, Urea and electrolyte, BP 2–4-weekly

(BP = blood pressure; FBC = full blood count; LFT = liver function tests)


Systemic corticosteroids have disease modifying activity. But their primary role is in the induction of remission in many diseases particularly in collagen diseases, rheumatoid arthritis, vasculitis and seronegative arthritis. They act by inhibiting prostaglandin synthesis. Prednisolone and triamcinolone are used as intra muscular or intra articular injections or orally. Side effects are GIT ulcers, cushing syndrome, glaucoma, weight gain, osteoporosis, high blood pressure, cataract etc

Biological therapy (arthritis medications biologics)

The use of biological agents (often abbreviated to ‘biologics’)  is  reserved  for  the  treatment  of  patients  who have  high  disease  activity  despite  having  had  an  adequate  trial  of  traditional DMARDs.  These  agents  are targeted  towards  specific  cytokines  and  other  cell surface  molecules  regulating  the  immune  response. Although generally well tolerated, biological  therapies increase the risk of serious infections due to suppression of the immune response.

Some biological agents are: Rituximab, Abatacept, Anakinra, Tocilizumab, Infliximab, Etanercept, Adalimumab.

know about natural remedies of arthritis

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