Jo Waters looks at the latest ways of treating the condition and current guidelines on safe use of painkillers

Arthritis is a growing problem in the UK as life expectancy increases and rates of obesity rocket, putting millions of hip and knee joints under more pressure. There are 200 type of arthritis, which are classified into three types: inflammatory arthritis, non-inflammatory arthritis and connective tissue diseases.

Osteoarthritis, which causes major problems with joint pain, poor quality of life and limited mobility, is the most common kind and is increasingly common with age. Twenty-five per cent of people over 55 have knee pain and 10 per cent of people in this age range will have moderate problems due to knee osteoarthritis[1].

The Health and Safety Executive estimate that musculoskeletal conditions cost the economy £5.7bn a year[2] and arthritis and related conditions are the second most common cause of days off work[3].

The majority of your patients with arthritis are not under the care of a specialist[4] and will either be seeing their GP or self-medicating, most of them in search of effective pain relief and others looking for supplements to help prevent inflammation.

Professor Rob Moots, Professor of Rheumatology at Liverpool University, says: "The vast majority of people with osteoarthritis will be either self-medicating or under the care of their GP - it's only the tip of the iceberg that comes to see a specialist like me for joint replacement. Patients with rheumatoid arthritis, on the other hand, are much more likely to be under the care of a specialist.

"Pharmacists have an important role to play in educating patients about self-help measures like losing weight and taking more exercise, which have both been shown to help improve symptoms in patients with osteoarthritis."

Pain relief options

Pain relief options for arthritis include paracetamol, oral and topical non-steroidal anti-inflammatories (NSAIDs), compound analgesics such as co-codamol, synthetic opioids such as tramadol, and skin patches.

Patients with more severe arthritis pain or who have suffered gastric side-effects from NSAIDs such as ibuprofen may be prescribed Cox-2 inhibitors by their specialist with proton pump inhibitors (PPIs).

The latest NICE guidelines[5] on management of osteoarthritis published in February 2008 advises:

  • Health care professionals should consider offering paracetamol for pain relief in addition to core treatment.
  • Topical NSAIDs and/or paracetamol should be considered ahead of oral NSAIDs, Cox-2 inhibitors or opioids.
  • Patients should be advised to lose weight and take exercise.
  • Oral NSAIDs or Cox-2 inhibitors should be used at the lowest possible dose for the shortest periods of time.
  • Other analgesic options should be considered for osteoarthritis patients who are taking low dose aspirin before substituting or adding an NSAID or Cox-2 inhibitor (with a PPI).

Are NSAIDs safe?

The British National Formulary states[6]:

"Cox-2 inhibitors are associated with an increased risk of thrombotic events (e.g. heart attack and stroke) and should not be used in preference to non-selective NSAIDs except when specifically indicated (i.e. for patients at a particularly high risk of developing gastro duodenal ulceration or bleeding) and after assessing their cardiovascular risk.

"Non-selective NSAIDs may also be associated with a small increased risk of thrombotic events particularly when used at high doses and for long-term treatment. Diclofenac (150mg daily) and ibuprofen (2.4g daily) are associated with an increased risk of thrombotic events. Naproxen is associated with a lower thrombotic risk, and low doses of ibuprofen (1.2g daily or less) have not been associated with an increased risk of myocardial infarction. A small increased thrombotic risk cannot be excluded for other NSAIDs."

"Pharmacists have a valuable role here in quantifying risk to patients so they are able to weigh up the risks versus the benefits of using NSAIDs and Cox-2 drugs," says Professor Moots.

"Patients will have read scary newspaper headlines saying these drugs double the risk of heart attack or stroke - but pharmacists will be able explain that this is still a very small risk and put it into context. For instance, they could explain that these studies were done on patients on very high doses for prolonged periods and that most people take much lower dosages and don't take them every day.

"It's much trickier when it comes to advising older people with arthritis pain who already have high blood pressure, unstable angina or heart failure or suffered a heart attack - it may be that the risk of taking those drugs is just too high for them. They may be better off with a compound analgesic, a transdermal patch or a drug such as tramadol.

"What is clear, though, is that there should be no blanket ban on different classes of drugs - for each one the risks need to be weighed against the benefits and discussed in the context of the individual patient's circumstances."

Further advice on the prescribing issues surrounding oral and topical NSAIDs is available on the NHS Clinical Knowledge Summaries website[7]. It also advises paracetamol and/or topical NSAIDs as a first line treatment and only recommends oral NSAIDs or Coxibs if the above are ineffective and then only if prescribed with a proton pump inhibitor to stop gastro side-effects. It reiterates that patients on low-dose aspirin should avoid taking low-dose NSAIDs if possible.

What about supplements?

Mintel figures from May 2007 show that omega-3 products and the supplement glucosamine were the only specific product sectors to have experienced growth in the vitamins and mineral supplement sector in the review period.

Sales of omega-3 supplements rose from £5m in 2002 to £22m in 2006, a 340 per cent increase; sales of glucosamine rose 900 per cent over the same period from £2m to £20m.

Other products containing rosehip and the herbal remedy devil's claw are also becoming more widely known about (see 'Latest remedies' box).

Despite their high sales volume, medical experts remain largely sceptical about the effectiveness of supplements. For instance, the NICE guideline on osteoarthritis specifically states that glucosamine is not recommended for osteoarthritis.

Professor Moots says: "There is no good evidence to support the prescription of glucosamine for joint pain in osteoarthritis or any other supplement for that matter. But there is some evidence that taking a fish oil supplement may reduce inflammation in rheumatoid arthritis."

Research carried out in Dundee and Edinburgh published in March 2008 in the journal Rheumatology found 40 per cent of arthritis patients who took cod liver oil supplements were able to reduce their painkiller use by 30 per cent.

Glucosamine supplements are not suitable for patients with seafood allergies and patients who are on anticoagulant treatment or diabetics should consult their doctor before taking fish oil supplements[8].

Role of pharmacists in arthritis care

The White Paper makes no specific mention of arthritis care but it does talk about the profession getting involved in the management of long-term chronic conditions - so it's potentially an area pharmacists may be asked to move into.

Rituximab and abatacept for rheumatoid arthritis

Rituximab (MabThera - Roche Products) and abatacept (Orencia - Bristol Myers Squibb) are drugs in two new classes, which are licensed for certain adults with rheumatoid arthritis[9].

Tocilizumab effective for arthritis

Evidence to support the effectiveness of tocilizumab, the first humanised interleukin-6-receptor monoclonal antibody, in patients with rheumatoid arthritis has been published in The Lancet[10]. A separate article shows promising results for tocilizumab in patients with juvenile idiopathic arthritis[11].

Latest remedies in the pharmacy

Voltarol Pain-eze (£5.99 for 18 tablets) was launched in October 2008. It is the first OTC diclofenac tablet, containing 12.5mg diclofenac potassium, and is marketed for joint pain, muscle aches and general body pain. It complements the family of Voltarol products already on sale in pharmacies. Novartis Consumer Health, tel: 01403 210211.

Anadin Joint Pain (£2.46 for 16 or £5.79 for 48 tablets) - two tablets of ibuprofen provide eight hours of pain relief to help arthritis suffers have an undisturbed night's sleep. Wyeth Consumer Healthcare, tel: 01628 669011.

A Vogel Atrosan Devil's Claw Tablets (£8.95 for 30, £15.95 for 60) contain the herbal remedy devil's claw (Harpagophytum) valued for its anti-inflammatory properties. It has been awarded a Traditional Herbal Medicines Licence for the relief of backache, rheumatic or muscular pain, and general aches and pains in muscles. Bioforce, tel: 01294 277344.

Jointace Gel (£7.95) is dual action massage gel that combines glucosamine and chondroitin with aromatherapeutic essential oils including ginger, clove bud and eucalyptus. Other products in the range include Jointace Collagen (£12.95 for 30 tablets), the Jointace Deep Aromatherapy Patch (£8.95 for 8) and Jointace Rose Hip and MSM (£12.95 for 30 tablets). Vitabiotics, tel: 020 8955 2600.

LitoZin(r) (£19.99 for 120 capsules or 100g powder). Herbal remedy derived from rosehips first discovered in Denmark 20 years ago. GR Lane, tel: 01452 524012.


  1. NICE Press Releases 27 Feb 2008: NICE guideline to improve care and management of osteoarthritis in adults (
  2. Buckle P, Stubbs D, Devereauz J. Musculoskeletal disorders prevention in the UK. University of Surrey, 2003.
  3. Arthritis: The big picture. ARC, 2002 (
  4. "87 per cent of people with arthritis or joint pain are not under the care of a rheumatologist or orthopaedic surgeon." Cited in Arthritis: The big picture. ARC, 2002 (
  5. Osteoarthritis: National clinical guideline for care and management in adults (
  6. BNF. Chapter 10. Sep 2008 (available online at
  7. Nonsteroidal Anti-Inflammatory Drugs (Standard or Coxibs): Prescribing issues ).
  8. Guide to Vitamins, Minerals and Supplements. Reader's Digest, 2000; p96.
  9. Rituximab and abatacept for rheumatoid arthritis. Drug and Therapeutics Bulletin 2008; 46(8): 57-61.
  10. Smolen JS, Beaulieu A, Rubbert-Roth A et al. Effect of interleukin-6 receptor inhibition with tocilizumab in patients with rheumatoid arthritis (OPTION study): a double-blind, placebo-controlled, randomised trial. The Lancet 2008; 371 (9617): 987.
  11. Yokota S, Imagawa T, Mori M et al. Efficacy and safety of tocilizumab in patients with systemic-onset juvenile idiopathic arthritis: a randomised, double-blind, placebo-controlled, withdrawal phase III trial. The Lancet 2008; 371 (9617): 998.

Jo Waters is a freelance health journalist who has worked for both specialist health trade titles and women's consumer magazines. She is Contributing Health Editor of Yours magazine and writes regularly for a selection of women's magazines. She is a former News Editor of General Practitioner magazine and past Features Editor of Top Sante (