David asked
Our 85 yr old mother needs some anti-inflammatory help for a 'stressed', slightly arthritic elbow. She is on Eliquis (apixaban) so we believe she should avoid any ibuprofen even topically applied. What other anti inflammatory meds could she take other than NSAIDs? (She had been taking Bonjela for her teeth gums which contains NSAID?)
Answer
Medication choice for arthritis depends on several factors, including what "kind" of arthritis your mother has. Arthritis of the elbow is most commonly osteoarthritis, which is the breakdown of the cushioning cartilage where bones meet at the joints. However, other forms of arthritis, such as rheumatoid arthritis could be the causative factor.
Non-NSAID Treatment For Osteoarthritis
While NSAIDs are generally recommended by most guidelines as a first line treatment of osteoarthritis, such as the one published by the American Academy of Orthopaedic Surgeons, many individuals are unable to take them due to complicating factors such as concomitant therapy with blood thinners. Therefore, many need to look to alternative treatments.
Non-NSAID treatment options include:
- Tylenol (acetaminophen)
- Topical capcaisin
- Tramadol
- Corticosteroid injections
- Topical NSAID (mixed evidence)
- SAMe
Below, we will discuss each in more detail.
Tylenol (Acetaminophen)
Although Tylenol is not a NSAID and does not have anti-inflammatory properties, it has shown to be able to provide effective pain relief in many suffering from osteoarthritis. In fact, it is usually the first recommended analgesic if a patient has complicating factors that precludes the use of NSAIDs, like being on blood thinner therapy.
Some studies even show that acetaminophen may be just as effective as ibuprofen for osteoarthritis. The American College of Rheumatology has recommended acetaminophen as first-line therapy for osteoarthritis of the hip or knee based on a 1991 study that showed acetaminophen 4 g/day (4,000mg) was as effective as ibuprofen in doses of 2.4 g/day (2,400mg) for the short-term relief.
Generally, it takes higher than usual doses of acetaminophen to provide effective relief for osteoarthritis pain. Tylenol is available in a "arthritis" strength of 650mg per tablet, 150mg over the extra strength product. Tylenol Arthritis is dosed as two tablets (1,300 mg) every 8 hours.
Topical Capsaicin
Capsaicin (the active constituent in chili peppers) topical preparations are a popular over the counter treatment but aren't specifically recommended in guidelines due to insufficient evidence. However, many small studies have shown benefit. As it is relatively safe to use and inexpensive, it may be worth considering as a treatment option.
Capsaicin is more often associated with the treatment of neuropathic pain, such as pain resulting from shingles. Nevertheless, studies have shown that it can also relieve pain due to rheumatoid arthritis and osteoarthritis, as well as back pain and jaw pain.
Tramadol
Tramadol is a prescription opioid medicaiton, but is also thought to affect various neurotransmitters as well, including norepinephrine and serotonin. While tramadol may not be an ideal choice, due its potential for dependence and greater side effects (such as constipation and drowsiness), it is listed among the therapy options in most guidelines, so I wanted to include it as an option to speak to the doctor about.
Tramadol isn't considered as strong as other opioids such as hydrocodone and oxycodone, but I don't want to downplay the potential for greater side effects than over the counter options.
Tramadol is generally dosed 2 to 4 times a day, with each dose lasting 4 to 6 hours.
Corticosteroid Injections
Like tramadol, steroid injections are most likely not ideal as they are via prescription only and are generally administered by a physician. Nevertheless, the relief from these injections is often superior to other treatments. If the symptoms of the arthritis are particularly bad, or an exacerbation occurs, these might provide the most relief.
Topical Diclofenac
Diclofenac (brand name Voltaren in the United States) is a widely used medication for pain, inflammation and arthritis. It is however, a NSAID, just like ibuprofen and thus carries analgesic, antipyretic and anti-inflammatory properties (and possible blood thinning effects).
Whether or not topical NSAIDs, like diclofenac or ibuprofen, pose a serious risk of bleeding is inconclusive. For topical diclofenac specifically, the 1% gel has minimal absorption compared to the oral dose. Per the prescribing information for Voltaren:
"Systemic exposure with recommended use of Voltaren® Gel (4 x 4 g per day applied to 1 knee) is on average 17 times lower than with oral treatment. (Basis: treatment with Voltaren® Gel of 1 knee, 4 times a day versus 50 mg, 3 times a day of oral diclofenac tablets). The amount of diclofenac sodium that is systemically absorbed from Voltaren® Gel is on average 6% of the systemic exposure from an oral form of diclofenac sodium."
Other studies have found similar results. One study, published by the American College of Clinical Pharmacology reported the following:
"Systemic exposure with diclofenac sodium gel 1% was 5‐ to 17‐fold lower than with oral diclofenac. Systemic effects with topical diclofenac were less pronounced."
The benefits of diclofenac gel may outweighs the risks in those treating osteoarthritis. Nevertheless, as some topical diclofenac is absorbed, there may still be an increased bleeding risk in those taking anticoagulants. Be sure to ask the doctor regarding this treatment option.
SAMe
SAMe is a natural compound known to have both analgesic and anti-inflammatory properties. It is thought to increase synovial fluid and stimulate cartilage growth and repair. SAMe is is touched on in various guidelines for osteoarthritis but not specifically recommended due to the lack of data behind it.
However, there have been numerous clinical trials show that taking SAMe is superior to placebo and comparable to NSAID therapy. In addition, SAMe is associated with fewer side effects than NSAIDs and is comparable in reducing pain and improving functional limitation. It should be noted that symptom relief with SAMe may require up to 30 days of treatment.
One study, published in BMC Musculoskeletal Disorders, even reported results that SAMe, while taking longer to be effective, provided similar pain relief to Celebrex (celecoxib), a commonly prescribed NSAID.
SAMe should not be used if you are taking antidepressants as it is thought to increase serotonin levels. An increase of serotonin may also slightly increase the risk of bleeding, but the risk appears to be minimal.
Additional Information
The medication mentioned in your question, Bonjela, contains choline salicylate, a derivative of aspirin. So yes, that would technically be classified as containing a NSAID.
