Anti-Inflammatory Medications

What are NSAIDs and COXIBs? 

Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medication used to treat the pain and inflammation of arthritis. They do not contain steroids, hence the name “non-steroidal.” NSAIDs are a very large category of medications, some of which you can obtain without a prescription, such as acetylsalicylic acid (ASA) (e.g., Aspirin®, Entrophen®, Novasen®), ibuprofen (e.g., Motrin® or Advil®) and naproxen (Aleve®). The list of NSAIDs is long, with more than 20 currently available. A COXIB (i.e., celecoxib (Celebrex®)) is an NSAID that has been custom-designed to minimize the risk of stomach ulcers. Although COXIBs are safer on the stomach, they still have all of the other side effects of NSAIDs and may still cause indigestion, nausea, stomach cramps and heartburn.

What are NSAIDs and COXIBs used for?

NSAIDs and COXIBs are used for both inflammatory arthritis and osteoarthritis (OA). For the treatment of OA, NSAIDs and COXIBs are a first-line treatment option. For treatment of inflammatory arthritis, NSAIDs and COXIBs help to control symptoms and do not alter the course of the disease. They are used as adjuncts to DMARD or biologic treatment.

They can be taken on an as-needed basis or they can be taken regularly to help control symptoms. Your health-care provider will advise you on the best way to take NSAIDs and COXIBs. 

How long do NSAIDs and COXIBs take to work?

Some people will notice the effects of NSAIDs and COXIBs within the first few hours of taking a dose. In other people, the effects may not be evident for a few days and even up to a week or two after the medicine has been started. If it hasn’t helped within two to three weeks, it is unlikely to be of much benefit.

How are NSAIDs and COXIBs administered? 

NSAIDs are typically taken by mouth in pill form. 

Diclofenac is an NSAID available as a topical preparation sold under the brand name of Pennsaid® and Voltaren Emulgel®. Pennsaid® is a prescription medication that can be used to help lessen the pain of arthritis. Voltaren Emulgel® is available over-the-counter and is indicated for relief of pain associated with recent muscle or joint injuries. When applied as directed to the skin over a joint, very little of the medication is absorbed into the body, which significantly reduces the usual side effects associated with NSAIDs. 

Which NSAID or COXIB is right for you? 

Your health-care provider may ask you to try a few different NSAIDs, as some may work better for you than others; what works varies from person to person.

How long will I have to take my NSAID or and COXIB?

If you have pain from OA that is present most of the time, your prescriber may recommend that you take NSAIDs or COXIBs regularly. If your OA pain is not persistent, you may be able to take your NSAID as needed. 

Inflammatory arthritis is a chronic condition that will likely require life-long treatment. This treatment may include NSAIDs or COXIBs taken regularly or when needed, however, inflammatory arthritis typically requires the use of a DMARD or biologic medication (see DMARDs and Biologics).

What are the risks of heart attack and stroke with NSAIDs and COXIBs?

Health Canada and the U.S. Food and Drug Administration (FDA) have reviewed all of the available studies on NSAIDs and COXIBs. Both groups have found that NSAIDs and COXIBs are associated with an increased risk of cardiovascular events (e.g., angina, heart attacks and strokes).

NSAIDs increase the risk of cardiovascular events, but in a small way compared to other risk factors. For example, high blood pressure and smoking pose a greater risk than taking NSAIDs.

The risk is greatest in those patients who use these medications for long periods of time and have risk factors for, or a history of, cardiovascular disease. Health Canada’s recommendations are as follows:
  • Do not use NSAIDs or COXIBs directly before, during or after heart surgery (bypass surgery).
  • Patients with a history of cardiovascular disease (e.g., angina, heart attack, TIA, stroke or congestive heart failure) should be careful using NSAIDs or COXIBs.
  • Patients with risk factors for cardiovascular disease (e.g., diabetes, smoking, elevated cholesterol, obesity and family history) should also be careful using NSAIDs and COXIBs. Safer alternative treatments should be used if available.
  • NSAIDs and COXIBs should be used in the lowest effective dose for the shortest possible duration of time.

If you have cardiovascular disease or risk factors for cardiovascular disease and require an NSAID your prescriber may recommend naproxen. Naproxen has been found to have the lowest risk (among NSAIDs) for cardiovascular events. Please discuss this issue with your health-care provider. 

What are corticosteroids?

Cortisol is a hormone produced naturally by the body’s adrenal glands that has many functions in our bodies. One of cortisol’s important actions is its anti-inflammatory function. Cortisol can be considered the “brake” for our immune system, preventing it from overreacting to infections, injuries and trauma. However, our bodies cannot produce enough cortisol to meet the challenge of inflammatory arthritis. Corticosteroids, such as prednisone, mimic the anti-inflammatory action of cortisol in our bodies and help to relieve pain and swelling from arthritis. Corticosteroids are commonly referred to as steroids.

Steroids are very effective at reducing inflammation, but a major limitation to their long-term use is adverse effects.

What are corticosteriods used for?

Steroid injections may be used to manage acute pain and inflammation associated with osteoarthritis (OA). The oral steroid prednisone is not routinely used or recommended for the management of OA. 
Steroid injections or oral prednisone may be used to help relieve pain and swelling associated with inflammatory arthritis.   

How long do corticosteroids take to work?

Steroids work quickly (usually within a few days) and some patients start to feel better within hours of getting the injection.

How are corticosteroids administered?

Steroids may be taken orally in pill form or injected directly into a joint or around a tendon.

Which corticosteroid is right for you? 

For patients with OA, a steroid injection into an affected joint may be considered if all other treatment options have failed to provide relief of pain and swelling.

For patients with inflammatory arthritis your health-care provider may recommend oral steroids or steroid injections depending on your individual condition. 

How long will I have to take my corticosteroids?

Only a health-care provider can make this decision since it depends on a person’s individual condition. For inflammatory arthritis, steroids are often used as an interim measure to help control inflammation while waiting for the slower-acting disease-modifying anti-rheumatic drugs (DMARDs) to take effect or in the case of someone experiencing a flare of inflammatory arthritis. Ideally, steroids should be used at the lowest dosage that provides benefit for the shortest period of time.

Typically, steroids do not play a significant role in the long-term management of osteoarthritis.

What is viscosupplementation?

Viscosupplementation is the injection of a clear gel-like substance called hyaluronan into the joint for the treatment of osteoarthritis (OA). Hyaluronan is an important part of the synovial fluid (thick liquid that lubricates the joint) and cartilage. Injecting it into the joint is thought to lubricate the joint (much like oil lubricates an engine), reduce pain and allow greater joint movement.

What is viscosupplementation used for?

These injections have been shown to have modest benefits in mild to moderate OA of the hip and knee.
Viscosupplementation injections are not routinely recommended for treatment of OA due to limited benefits, risk of side effects and high costs of the various agents available.

How is viscosupplementation administered? 

Some products are given as a one-time single injection, while others are injected once weekly for either three or five weeks. 

Viscosupplementation products can be purchased without a prescription, but it is necessary to see a health-care provider for the injection.

Which viscosupplementation agent is right for you?

For patients with OA, a viscosupplmentation injection into an affected joint may be considered if all other options have failed to provide relief of pain and swelling. There is no information to suggest that one viscosupplementation product is better than another and response to these agents varies from person to person.

How long will I have to use viscosupplementation?

These injections may be repeated at a later date if they are felt to be helpful; however, the effect of repeated injections is unknown. Typically, viscosupplementation does not play a significant role in the long-term management of OA.

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