ARTHRITIS OF THE KNEE JOINT

7. Non-Steroidal Anti-Inflammatory Drugs NSAIDs (Pronounced EN-seds), are a group of drugs which decrease the inflammation (pain and swelling) in arthritic joints. The pain relief from NSAIDs can be quite amazing. Although they are commonly referred to as “arthritis pills”, none of them will in any way influence the outcome of the arthritis. There are many NSAIDs available, and newer ones are constantly being brought onto the market. The “newest” one is not necessarily the most effective. Most people respond better to one NSAID than to another, and you may have to try several before the “right” one can be found for you. They all have potentially serious side effects and should only be taken under medical supervision. Most can only be obtained by prescription and are expensive. Aspirin (which is also an NSAID!) is cheap, and is often just as effective as any of the other NSAIDs. It should therefore be tried first. If even coated aspirin (Ecotrin) affects your stomach, then try extra-strength Tylenol. Most NSAIDs are “COX I Inhibitors.”

COX II Inhibitors - A New Class of NSAIDs

Vioxx, Celebrex, Bextra and Mobic, the newest NSAIDs on the market, are “COX II Inhibitors.” In general, these drugs have been found to be slightly more effective than most (but not all) of the older, COX I, NSAIDs, but this is not true for all patients. They have much fewer side effects than COX I inhibitors, but side-effects are not eliminated. Celebrex and Bextra cannot be taken by people allergic to sulfa. Vioxx and Celebrex can elevate the blood pressure if you already have hypertension by counteracting the effectiveness of some blood pressure medications known as “ACE Inhibitors”. Vioxx has been associated with increased heart problems and stroke. The incidence is small, and may be worth the risk. Discuss this with your prescribing doctor.

Side Effects of NSAIDs

Please read this section carefully if Dr. Huddleston has prescribed NSAIDs for you.

About 30% of patients on NSAIDs can expect some side effects. Most side effects are mild and may go away without treatment. Others are more serious and should be treated right away.

Stomach Problems: Stop the medication immediately if you get stomach pain, cramping or burning. Check with your doctor if you get nausea, constipation or diarrhea which lasts for more than three days.

Fluid Retention: This may happen if the NSAIDs affect your kidney function. You may notice swelling of the ankles, feet, or lower legs, or an unusual weight gain. If this continues for more than two weeks, check with your doctor. Vioxx is prone to causing fluid retention.

Bruising Tendency: NSAIDs interfere with the clotting of blood and may cause you to bruise easily. If you have any bleeding problems or take blood thinners, check with your doctor before taking NSAIDs.

Dizziness, Lightheadedness, or Drowsiness: These are rare. If they do occur they usually go away when your body adjusts to the medicine.

Stomach Ulcers: Some people taking NSAIDs develop stomach ulcers, and occasionally these may bleed. The bleeding can come with very little warning, and can even be severe enough to cause death. This is why stomach symptoms should be taken very seriously in patients on NSAIDs.

Note that iron pills (taken for anemia or during the period you are giving blood for auto transfusion) will also turn your stools pitch black.

Most people can take NSAIDs without having stomach problems. However, you may have a higher risk if you have had previous ulcers, or are over the age of 60, use cortisone (such as Prednisone), smoke or drink alcohol. If you are in any of these high risk categories, it is recommended that you take Cytotec (which helps to protect the stomach) in addition to the NSAID. Cytotec is not routinely prescribed as it is expensive and has side effects of its own. There are other medications which can help protect the stomach.

Drugs that may interact with NSAIDs

Some drugs may interact adversely with NSAIDs. In some cases the combination should be avoided completely; in others, the dosage of either drug may need compensatory adjustment.

If you are taking any of the following drugs, consult your internist before commencing treatment with NSAIDs. There may be others not included in this list: aspirin, lithium, phenytoin, methotrexate, digoxin, probenecid, barbiturates, anticoagulants, high blood pressure medications, antacids, oral diabetes medications or diuretics.

Allergy to the NSAIDs: This may be manifested as rapid breathing, gasping, wheezing, fainting, hives, itching, skin rash, rapid heart beat, or sudden puffiness of the eyelids. Allergy is exceedingly rare. It occurs sometimes in people who are truly allergic to aspirin. If you have these symptoms and you do not have someone to drive you to the hospital, call an ambulance and get to the hospital as soon as you can, since the allergic reaction could be severe and need urgent medical treatment.

The reason for discontinuing these medications is that they can increase bleeding at the time of surgery. Tylenol, Darvocet, and Tylenol with Codeine can be taken by mouth up to the night before the operation. If you have an uncemented implant, you should not use Indomethacin after surgery unless approved by Dr. Huddleston, since it may interfere with bone-ingrowth into the implant surface.

* Can affect liver or kidneys. Need to have blood tests every 3-6 months (Complete Blood Count, Liver Function Tests, serum creatinine).
+ Can elevate blood pressure.

1. Tell your doctor if you are taking any other prescription or over-the-counter medications. Also if you have any other medical problems, especially stomach ulcers, bleeding tendency, colitis, diverticulitis (or other stomach or bowel disease), kidney disease, asthma or liver disease.
2. Always take NSAIDs with a meal and plenty of liquids.
3. Don’t exceed the dose prescribed by your doctor if it doesn’t seem to be working to your satisfaction. There is a maximum effective dose for each NSAID and it could be very harmful to exceed that dose.
4. Don’t take NSAIDs only when you have pain or only when you expect to have pain (such as before a game of golf). NSAIDs may take up to two weeks to reach their full effect.
5. Don’t take NSAIDs with alcohol or caffeine-containing beverages. These beverages make stomach problems worse.
6. Don’t simultaneously take other medications containing aspirin compounds or ibuprofen. Taking the prescribed NSAID in addition may cause side-effects from to much NSAID in your BODY onunload="leave()" . You can take Tylenol together with any of the NSAIDs.
7. Don’t drive or operate machinery if your NSAID makes you feel drowsy or dizzy.

7. Pain Medications: Eventually NSAIDs will not give you adequate relief. If for some reason you are not able to undergo hip surgery by that time, then your only recourse is to take pain medications, starting with over-the-counter medications such as Tylenol, and progressing to stronger prescription medications from your doctor as necessary.

   The following are some commonly prescribed pain medications:

8. Glucosamine Sulfate/Chondroitin Sulfate (“chondroprotective agents or nutraceuticals”) are in widespread use for the treatment of arthritis. There is some scientific evidence that they may slow the arthritic process (Journal of Arthroplasty, April 2003), and that they have a pain-relieving, NSAID-effect without the side-effects of NSAIDS (Journal of the American Academy of Orthopaedic Surgeons, March 2001). The dose is 1500 mg of Glucosamine plus 1200 mg of Chondroitin taken once a day. They give the best results when taken together. SAM-e, MSM and CMO are other neutraceuticals widely used even though there is less evidence for their efficacy.
9. Hyalgan, Synvisc and Supartsz (“viscosupplementation”) are clear liquids purified from rooster combs. They increase the viscosity of joint fluid and the elasticity of the joint cartilage, and are also thought to have a weak NSAID (pain-relieving) effect. It only stays in the joint for about 48 hours, but the improvement can last for six to 12 months. It works best on mild to moderate arthritis. Repeat courses can be given every 6 to 12 months if it works well. FDA approval is only for use in the knee, but it can be used “off label” in the hip joint. A series of three or five injections are given into the joint. You cannot have these injections if you are allergic to eggs or feathers. Synvisc sometimes causes severe inflammation and swelling in the knee. Dr. Huddleston prefers Hyalgin because the side effects are negligible.