This guide summarizes clinical evidence on the effectiveness and safety of non-opioid analgesics for osteoarthritis. It covers most available over-the-counter (OTC) medications and prescription non-steroidal anti-inflammatory drugs (NSAIDs). The reviewed drugs are listed below. This guide does not address non-pharmacologic therapies such as diet, exercise, acupuncture, or surgical interventions.

Clinical Issue

Twenty-one million Americans have osteoarthritis. It is a chronic condition associated with pain and substantial disability. Managing pain can assist in maintaining mobility and improving quality of life. Choosing among the available prescription and over-the-counter medications requires careful consideration of benefits, risks, and cost.

The categories of non-opioid drug treatments for osteoarthritis are:

• Acetaminophen.
• NSAIDs, including aspirin and celecoxib.
• Glucosamine and chondroitin.
• Topical medications (including capsaicin, topical salicylates, and topical NSAIDs).

Clinical Bottom Line

• Acetaminophen relieves mild pain but is inferior to NSAIDs for reducing moderate or severe pain. Acetaminophen has fewer systemic side effects than NSAIDs.
  Level of confidence:
• All non-aspirin NSAIDs work equally well for pain reduction.
  Level of confidence:
• NSAIDs increase the risk of GI bleeding. The risk increases with higher doses and with age. People older than 75 have the highest risk.
  Level of confidence:
• Celecoxib, high dose ibuprofen, and high dose diclofenac increase the risk of myocardial infarction. Naproxen does not increase the risk of myocardial infarction.
  Level of confidence:
• Capsaicin cream relieves chronic osteoarthritic pain, but about half of the people using it will experience local burning sensations. The burning diminishes over time.
  Level of confidence:
• OTC topical creams containing salicylates do not reduce osteoarthritic pain.
  Level of confidence:

Assessing Risk of Complications

Alternatives to Oral NSAIDs

• Consider glucosamine and chondroitin. Pharmaceutical grade glucosamine hydrochloride (1500 mg a day) plus chondroitin sulfate (1200 mg a day) reduces moderate to severe pain without serious side effects, but this combination has no effect on mild pain. The Food and Drug Administration (FDA) does not regulate these supplements as drugs, so the purity may vary.
  Level of confidence:
• Consider acetaminophen. For mild pain, it is an effective alternative to NSAIDs.
  Level of confidence:
• Consider capsaicin cream. It relieves chronic osteoarthritic pain, but about half of the people using it will experience local burning sensations. The burning diminishes over time.
  Level of confidence:
• Consider topical creams containing prescription NSAIDs. They work as well as oral NSAIDs for osteoarthritic pain relief and have fewer systemic side effects. Topical diclofenac and topical ibuprofen are the best studied topicals. The FDA has not approved any topical NSAID formulations, but compounding is widely available.
  Level of confidence:

Still Unknown

• There have been few studies comparing aspirin or salsalate to other NSAIDs for the treatment of osteoarthritis.
• We do not have enough data to make reliable judgments about the cardiovascular risks of many oral NSAIDs. The drugs most studied are celecoxib, ibuprofen, diclofenac, and naproxen.
• There is insufficient evidence to assess whether therapeutic doses (up to 4 grams a day) of acetaminophen lead to liver abnormalities in people without underlying liver disease.
• Results from recent observational studies suggest an increased cardiovascular risk with heavy use of acetaminophen, but large, long-term trials of acetaminophen and associated cardiovascular safety are lacking.
• It is not known whether using celecoxib is a better strategy than adding a PPI or misoprostol to a conventional NSAID for lowering the risk of GI bleeding.

Doses and Price

Resource for Patients

Choosing Pain Medicine for Osteoarthritis: A Guide for Consumers is a companion to this Clinician’s Guide. It can help people talk with their health care professional about pain relief options. It provides information about:

• Types of over-the-counter and prescription pain relievers.
• Benefits, risks, and price of pain relievers.

For More Information

For electronic copies of the consumer’s guide, this clinician’s guide, and the full systematic review, visit this Web site: www.effectivehealthcare.ahrq.gov

For free print copies call:

The AHRQ Publications Clearinghouse (800) 358-9295

Consumer’s Guide, AHRQ Pub. No. 06(07)-EHC009-2A

Clinician’s Guide, AHRQ Pub. No. 06(07)-EHC009-3

Source

The source material for this guide is a systematic review of 351 research publications. The review, Comparative Effectiveness and Safety of Analgesics for Osteoarthritis (2006), was prepared by the Oregon Evidence-based Practice Center. The Agency for Healthcare Research and Quality (AHRQ) funded the systematic review and this guide. The guide was developed using feedback from clinicians who reviewed preliminary drafts.

AHRQ created the John M. Eisenberg Center at Oregon Health & Science University to make research useful for clinicians. This guide was prepared by David Hickam, M.D., Roger Chou, M.D., Valerie King, M.D., Theresa Bianco, Pharm.D., Sandra Robinson, M.S.P.H., and Martha Schechtel, R.N., of the Eisenberg Center.