Doctor. Do Rubs Work For Arthritis?

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.

About The Author: Nathan Wei, MD FACP FACR is a rheumatologist
and Director of the Arthritis and Osteoporosis Center of
Maryland. He is a Clinical Assistant Professor of Medicine at
the University of Maryland School of Medicine. For more info:
http://www.arthritis-treatment-and-relief.com/arthritis-treatment.html