If you have osteoarthritis, what's your best first line of defense against painful joints? Dr. Clifton O. Bingham III, Director of the Johns Hopkins Rheumatology Clinics, offers advice.
Q. Which pain medication has the best risk-to-benefit ratio for osteoarthritis?
Dr. Bingham: Overall, acetaminophen (Tylenol) is the safest, which is why it stands at the top of treatment recommendations for patients with osteoarthritis. As a first treatment, acetaminophen has been shown in some studies to be just as effective as most NSAIDs and is less likely to cause side effects such as stomach irritation. It’s also inexpensive.
Q. What dosage of acetaminophen do you recommend for effective osteoarthritis pain relief?
Dr. Bingham: Acetaminophen can effectively treat pain and provide enough relief so that many people with osteoarthritis can engage in more physical activity. As with every pain medication for osteoarthritis, we’ve learned that the lowest effective dose is the best dose. That's because increasing doses of any drug, including acetaminophen, are associated not only with increased pain relief but also an increased risk of side effects, which may tilt the risk-to-benefit ratio toward the riskier side.
The maximum recommended daily dosage of acetaminophen is 4,000 mg, generally taken as 1,000 mg four times a day, or as extended release or arthritis strength (1,300 mg three times a day). When taken regularly, dosages above that amount can cause dangerous side effects. Acetaminophen may be harmful for people who have liver disease or who drink large amounts of alcohol. To decrease risk of liver damage, you should not consume alcoholic beverages while taking this medication.
Acetaminophen may also be dangerous if you are taking the blood-thinning drug warfarin (Coumadin). Some research indicates that, in rare cases, heavy daily use of acetaminophen may increase the risk of kidney damage.
Important note: If you take acetaminophen for osteoarthritis, it's important to recognize that other over-the-counter preparations such as cold medicines or multi-symptom relievers often also contain acetaminophen. Therefore, if you combine the two, it's possible to get a cumulative dosage that exceeds recommended safety levels.
Q. If acetaminophen doesn't work, what are the risks and benefits of switching to traditional NSAIDs?
Dr. Bingham: Aspirin, the original NSAID, is an effective and inexpensive treatment for osteoarthritis pain, but high doses have significant side effects on the stomach. You can consider other over-the-counter NSAIDs such as ibuprofen (Advil and others), naproxyn (Aleve and others), and ketaprofen (Orudis KT).
NSAIDs work primarily as pain relievers, but also decrease inflammation, which may be present in over 30% of individuals with osteoarthritis. How osteoarthritis symptoms respond to a specific NSAID varies greatly from person to person. As a result, finding the right drug largely depends on trial and error. On average, it can take at least two weeks of treatment with a drug to know if a particular drug is effective.
As with all medications, there are risks as well as benefits, even with over the counter medications. Acetaminophen is safe for many people, but speak with your doctor about which pain reliever is right for your arthritis given your personal health history, such as a history of high blood pressure.
