A guide to arthritis treatments

Analgesic is another word for painkiller. Paracetamol is a common analgesic. It is short acting and can be used to treat mild to moderate pain. It is sometimes used in addition to other medicines.

You can buy some analgesics, like paracetamol, over the counter in pharmacies or supermarkets, but as this drug may be part of the chemical make-up of other stronger analgesics it is always advisable to check if you are safe to take paracetamol with your other prescribed medication, to reduce risk of overdose. Again, if in doubt, ask

Stronger analgesics, such as compound analgesics (for example co-codamol and tramadol) and opioid analgesics, for treating more severe pain, must be prescribed by a doctor. For some, side effects may occur, such as feeling “a bit spaced out”, so it helps to know what to look out for.

Analgesics shouldn’t be taken in high doses for long periods of time. If you are requiring analgesics regularly in high doses for long periods of time, it is advisable to ask your rheumatology doctor to review your symptoms and medication to help you get a better response and gain greater control of your symptoms.

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Your GP, or a qualified pharmacistat your local chemist, may also be a helpful person to talk to about the safe use of medicine. Using a dosette box, a kind of weekly tablet box, is also helpful to keep you on track if you have several pills to take at different times.

It is also valuable to be mindful that in some situations, tablets aren’t always the best answer for pain relief. There are many other options that may help you gain relief, including heat or cold packs, ointments and muscle rubs, TENS machines, and even hydrotherapy and exercise.

It is helpful to gain a little knowledge about different types of pain and what options may give effective relief. Your doctor, nurse or physiotherapist may be able to advise on options depending on your symptoms.

Medicines in this group help to reduce pain, stiffness and swelling. There are different types, some slow release, helping ease symptoms for longer. Common NSAIDs are ibuprofen, naproxen and diclofenac. Following medical advice, they may be taken regularly to get the best effect.

If NSAIDs are to be taken for a length of time some people may benefit from taking a proton pump inhibitor (PPI), which is a drug that reduces stomach acid, to help protect the lining of the stomach. Examples of PPIs are Omeprazole and Lansoprazole. Ask your GP or consultant if this could apply to you. NSAIDs aren’t suitable for everyone, particularly if you are on other medication, so it is advisable for your wellbeing to avoid self-medicating, and if in doubt ask.

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As in the name, these medicines act by modifying the underlying disease rather than treating just the symptoms, which is really clever right? They’re not painkillers, but they reduce pain, swelling and stiffness over a period of weeks or months by slowing down the disease and its effects on the joints.

DMARDs are slow to act and can take several weeks, if not months, to work. As long as you have no side effects, you may need a little patience before you start to notice if they are working for you. Rings getting looser on fingers, or stiffness in the mornings easing that bit quicker may be signs of positive change, but it can be subtle to see, and not all change is visible to the eye. Your specialist team will regularly assess how your body is responding, to ensure you get the best from your treatment.

The most common DMARD is methotrexate. Research has proven it to be very effective at reducing inflammation, which in turn reduces joint damage, and slows down the progression of arthritis, particularly when people are diagnosed and treated early.

Commonly, methotrexate is taken for several years, and is advised to be carefully and regularly monitored for the length of time it is prescribed. It can be taken as a child or an adult, in tablet form, or as an injection to help reduce or stop side effects for the few that may have them.

Anti-sickness tablets (antiemetics) are tablets taken to reduce nausea. They can be helpful to reduce side-effects from certain medicines, while your body adapts. Metoclopromide is one often prescribed.

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Arthur’s Place founder, Advanced Rheumatology Nurse Practitioner Andrea McBride advises: “Try not to expect too much, too soon, from these medicines. They take a little while to kick in, so try not to judge them too quickly. Let your rheumatology team know how you are getting on, because they can advise about pain relief to help in the interim.”

It’s not just methotrexate, of course. There are many different DMARDs that can work very effectively, for lengths of time, to gain good control of your condition and protect your joints in the long term. In fact, it may take a little time for your medical team to find exactly the right DMARD, or combination of DMARDs, that works for you.

For some, a medicine may cause side effects. With your help, your team will monitor if you have any side effects, and advise you of possible solutions, or changes to your medicines that can improve how you feel. For some, starting the dose low and gradually increasing it can help reduce risk of side effects, as your body has more time to adapt. Keeping a record of symptoms can be helpful for both you and your team, particularly in the first few weeks.

“We understand how hard it can feel to keep positive whilst getting a diagnosis and treatment plan sorted,” says Nurse McBride: “But with a little patience, lots of support and a positive outlook, finding the right plan for you really can make all the difference.”

Finally, remember that while it is often tempting to compare your medicine plan to others, either someone in your family with a similar condition or other people with arthritis that you meet along the way, it can be unhelpful too. One size doesn’t fit all; what works for you may not be what works for someone else. Plus, the progression of the condition for one person is never identical for the next person. It may seem that you are taking the same path, but it doesn’t mean your treatment should be the same. Every case is individual.

These medicines have been around for just over the last decade or so. They’re commonly used in patients who have a limited response, no response, or are unable to tolerate methotrexate or similar medicines.

Biological therapies can slow down the progression of arthritis and in turn reduce pain, swelling and stiffness. Biological therapies are more commonly given as an injection, though some may be given in hospital via a drip (infusion).

Some biological therapies are called anti-TNF drugs. They target a protein called tumour necrosis factor, which increases inflammation when excess amounts are present in the blood or joints. Other biological therapies target different proteins.

Biologic drugs can help to block certain key points of the inflammatory pathway. They can be very effective, but they need careful supervision and they do have potential side-effects.

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A biosimilar medicine is a highly similar version of a reference biological medicine. The reference biological medicine is the first brand to market. To learn more about biosimilars watch this video.

People with arthritis may benefit on occasion from steroids. Like other drug therapies, steroids reduce inflammation, pain and stiffness, but this tends to be a short-term solution to ease symptoms. Steroids don’t control the inflammatory process in the way DMARDs or biological therapies do.

Steroids can be given in the form of tablets, through a drip, or in two different forms of injection: either into a muscle to get generalised relief, or into an affected joint, for targeted relief.

Steroid tablets (Prednisolone)

Steroid tablets may be prescribed as a short course to help quickly gain control if you are in a flare. For some they may be prescribed for a longer period of time, depending on your circumstances and how you have responded to your other medication.

Your pharmacist will provide you with an alert card, if appropriate for you, when you collect your prescription. It is advisable to carry it with you as a precaution, to advise others in an emergency that you are taking steroids.

It is very important that you always seek medical advice about how and when to stop taking steroid tablets. The majority of people will be recommended a gradually reducing dose to allow the body to readjust. Never dabble and always get advice from your doctor before doing anything.

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Steroid injections

An injection into a joint can be done under general anaesthetic for young children, but as you get older you can have the injection with a local anaesthetic.

To get the best response from this injection you may be advised to rest the joint for a period of time. For some this may affect how long it will last.

The benefit of this injection, in particular for knees, is that if there is a lot of fluid that is adding to your discomfort it will be drained away quite simply via the one injection. For many this will give some immediate relief.

The injections can be effective for several months and have few side-effects but may be limited to only so many over a twelve-month period. Your rheumatology team can advise you further.

There is also the option of a steroid injection into a large muscle. This will circulate around the whole body to help settle down several joints. The benefit of this type of injection is that it is not necessary to rest.

Either type of injection can be very effective. The length of time will vary from person to person but for many it can be effective for several months and have few side effects. It’s best to tell your team if you have any infections before having either procedure so they may offer advice.

In some cases, surgery may be recommended, to improve ability to function and get on with life independently, with far less discomfort or restriction.

Dr Moorthy Arumugam, consultant rheumatologist at the University Hospitals of Leicester NHS Trust, says: “Nowadays with modern, targeted treatment, surgery is less often required.”

However, some people with arthritis may benefit from surgery. It is important to note that surgery is never rushed into and is often only necessary as an absolute last resort for the few patients who don’t respond to other treatments, or experience complications.

Types of surgery that may be recommended are:

• Synovectomy– This is done to remove inflamed joint tissue (synovium) that is causing unacceptable pain or is limiting your ability to function. The procedure may be done using arthroscopy (keyhole surgery).
• Hip, knee, shoulder, or elbow joint replacement – Damaged joint surfaces are replaced with artificial parts. For some this type of surgery may significantly relieve pain, increase mobility and improve function.
• Foot, ankle, hand or wrist surgery– Occasionally patients may need this type of surgery, although it is possibly less common than surgery to the bigger joints.

Your Rheumatologist or GP can refer you to an Orthopaedic Consultant for opinion and advice.

For more information about surgery or medicines visit Versus Arthritis.

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