Osteoarthritis and the Side Effects of NSAIDs and Corticosteroids

Compiled by John G. Connor, M.Ac., L.Ac., Edited by Barbara Connor, M.Ac., L.Ac.

TABLE OF CONTENTS
Introduction
Research on the Health Benefits of Acupuncture on Osteoarthritis
Natural Compounds Effective in the Treatment of Osteoarthritis
Western Medical Treatment  – Drug therapies and their adverse effects
Conclusion
References

Definition & Population Affected:
Osteoarthritis refers to a degeneration of articular cartilage typically accompanied by sclerosis of subchondral bone and the creation of marginal osteophytes.  It is age related—those over 50 years old being in the most affected category.  People under occupational stress, those who are obese and those who have faulty posture are at greatest risk for the disease.  Trauma, such as sports injuries at an early age, can increase people’s susceptibility to osteoarthritis with advancing years.1 & 2

Importance of Osteoarthritis as a Health Issue:
Osteoarthritis is the most common rheumatic disease.  Approximately 37 million Americans have arthritis.9  Out of this total, about 16 million Americans have osteoarthritis.  Arthritis accounts for 9-15% of all visits to medical doctors.  The economic impact of these diseases amount to 35 billion dollars—12 billion dollars in medical costs and 23 billion dollars in lost productivity.10

• According to a study published in Ann Intern Med 2004 Dec 21;141(12):901-10 by Berman BM, Lao L et al entitled “Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial involving 570 patients with osteoarthritis of the knee it was concluded that acupuncture seems to provide improvement in function and pain relief as an adjunctive therapy for osteoarthritis of the knee when compared with credible sham acupuncture and education control groups.

• The results of a study published in Rheumatology (Oxford) 1999 Apr; 38( 4): 346-54 by Berman et al entitled “A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee” concluded that acupuncture is an effective and safe adjunctive therapy to conventional care for patients with osteoarthritis of the knee.

• The results of a study published in Danish in Acta Anaesthesiol Scand 1992 Aug; 36 (6): 519-25 entitled “Acupuncture treatment of severe knee osteoarthrosis. A long-term study” concluded that acupuncture on patients waiting for arthroplasty surgery can ease the discomfort while waiting for the operation and perhaps even serve as an alternative to surgery. Seven patients responded so well that at the time of publication they did not want an operation. Comparing the acupuncture treated group with the group receiving no acupuncture it was noted that there was a significant reduction in pain, analgesic consumption and in most objective measures. In the second part of the study it was shown that it was possible to maintain the improvements with once a month acupuncture treatments.

· Boswellia serrata extract – was shown to reduce pain rapidly, as early as after 1 week of treatment.  It reduces levels of the cartilage degrading enzyme MMP-3 in synovial fluid, and, most importantly it is safe for human consumption, even long term.  (Sengupta et al 2008)

· Scutellaria – was tested along with another natural compound called catechin and the combination was found to be as effective as naproxen in controlling the signs and symptoms of osteoarthritis of the knee. (Levy et al 2009) 

· Eleutherococcus senticoccus, Panax notoginseng and Rehmannia glutinosa – were found to be safe, tolerable and effective for symptomatic improvement of pain and physical function of knew osteoarthritis patients.  (Park et al 2009)

·   Curcumin and resveratrol combined may be a useful strategy in osteoarthritis therapy as compared with separate treatment with each individual compound. (Csaki et al 2009)

·   Eicosapentaenoic acid (EPA) was the most effective, followed by docosahexaenoic (DHA) and then alpha-linolenic (ALA) acid – These omega-3 (n-3) PUFAs cause a reduction in the mRNA levels for various proteins known to be important in the pathology of osteoarthritis. The relative efficacy of EPA suggests that this omega-3 PUFA may be especially useful for dietary supplementation in patients with osteoarthritis. (Zainal et al 2009)

. Vitamin D – Low dietary vitamin D intake increases the risk of progression of knee radiographic osteoarthritis. Particularly in subjects with low baseline bone mineral density, vitamin D status seems to influence the incidence and progression of knee radiographic osteoarthritis . Thus, improving the vitamin D status in the elderly could protect against the development and worsening of knee osteoarthritis, especially in those with low bone mineral density. (Bergink et al 2009) 

· Vitamin D – We observed a significant positive association between serum 25(OH)D and bone mineral density in individuals with primary knee osteoarthritis, independent of sex, age, BMI, knee pain, physical activity, and disease severity. Given the high prevalence of low 25(OH)D status in persons with knee osteoarthritis and the positive association between 25(OH)D and BMD, vitamin D supplementation may enhance bone mineral density in individuals with osteoarthritis. (Bischoff-Ferrari et al 2005)

·   Cat’s Claw (Uncaria tomentosa) – was found to be an effective treatment for osteoarthritis. (Piscoya ete al 2001)

WESTERN MEDICAL TREATMENT

1)   Physical Modalities:Regular exercise, avoiding harmful impact loading on joints and encouraging relatively atraumatic isometric exercises helps maintain the integrity of cartilage and increase the strength of joint stabilizing muscles.

2)   Drug Therapies and their Adverse Effects:  Non-steroidal anti-inflammatory drug (NSAID) therapy is a common treatment for relief of pain in osteoarthritis.  Examples of NSAIDs are ibuprofen, aspirin and acetaminophen.  Unfortunately, patients with osteoarthritis are often elderly and therefore are more susceptible to the serious toxicity (e.g., gastropathy, renal failure) of NSAIDs.  It is prudent, therefore, to use NSAIDs sparingly in this disorder.4 

NSAID-induced dyspepsia is the number one drug side effect in the U.S.11  Major side effects of NSAIDs include gastroenteropathy, kidney and liver dysfunction, CNS disturbances and hematological disturbances.  Some MD’s have recognized that the use of NSAIDs for arthritis treatment is so inappropriate that they have written articles to this effect and called for informed consent forms to be signed by the patient before taking these drugs.12 & 13  

NSAIDs play a role in 25% of all gastric ulcers14 and are considered a factor in 40-80% of all deaths from ulcer disease.  20% of all daily users have endoscopically diagnosed ulcers or erosions.15  The elderly are at greater risk, and they are four times more likely to die from ulcer hemmorhage.16  

In the kidneys, NSAIDs block several important counter regulatory processes.  This results in local vasoconstriction, decreased glomerular filtration rate, increased water retention, increased blood pressure and renal failure.3   Long-term use of NSAIDs also thin cartilage, making it undesirable for osteoarthritis sufferers.5  There is evidence that NSAIDs can actually accelerate osteoarthritis by inhibiting proteoglycan synthesis, thereby blocking cartilage formation and promoting cartilage destruction.8  

For patients with unrelenting joint pain, corticosteroids are often injected into the affected joint.  The adverse effects of corticosteroids are well documented.  Some examples are: “sodium retention, fluid retention and edema, congestive heart failure in susceptible patients, potassium loss and hypokalemic alkalosis, hypertension, muscle weakness (steroid myopathy), loss of muscle mass, osteoporosis with vertebral compression fractures, aseptic necrosis of femoral and humeral heads, pathologic fractures of long bones and spontaneous fractures.”6  Several other systems of the body are affected by corticosteroids including gastrointestinal, dermatologic, neurological, endocrine, metabolic and ophthalmic.7

3)   Surgery:
In extreme cases, surgery is recommended for remodeling or replacement of joints.  Surgery is always a traumatic experience, and since most people suffering from osteoarthritis are elderly, it is often not recommended.

CONCLUSION:
  In light of the above adverse side effects of NSAIDs and corticosteroids, it is obvious that other forms of non-invasive alternative therapies such as acupuncture, craniosacral acupuncture, nutritional supplements, Chinese herbs and homeopathy must be explored for treating osteoarthritis.  For more information on osteoarthritis and how Barbara and I treat it we refer you to our article entitled Rheumatic and Arthritic Conditions on our website.

REFERENCES
  1. Bullock, Barbara L., and Rosendahl, Pearl Philbrook, Pathophysiology, Philadelphia, J. B. Lippincott Co., 1992, p. 883
  1. Rakel, Robert E., M.D., Conn’s Current Therapy, 1994, Philadelphia, W. B. Saunders Co. 1994, p. 970
  1. Blackshear, J. L., et al. Identification of risk of renal insufficiency from NSAID. Arch Int Med. 1983;143:1130-4
  1. ibid. p.970
  1. Caradonna, Bill, Western Pharmacology Fall 1995-96 Class Notes
  1. ibid. Table 6
  1. Harvey, Richard A., Champe, Pamela C., Pharmacology, Philadelphia, J.B. Lippincott Co., 1992 pp. 252-258 & 361-377
  1. Lancet, Vol ii, 11-13, 1985
  1. Prevalence of arthritic conditions in the United States, JAMA, 1990; 263: 1758-9
  1. SmithKline Beecham launches NSAID: Drug Topics, April 20, 1992
  1. Cryer, B., et al. Strategies for Preventing NSAID Induced Ulcers: Drug Therapy, July, 1994: 24(7):26
  1. Dieppe, P.A., et al. Is research into the treatment of osteoarthritis with NSAIDs misdirected? Lancet, Feb. 6, 1993, Vol 341: 353-354
  1. Katz, J.N., et al, Informed consent and the prescription of NSAIDs Arthritis Rheum, 1992 35:1257-1263
  1. Carson, J.L., et al, The association of NSAID with upper GI bleeding Arch Int Med. 1987; 14785-8
  1. Kimmey, M.B. NSAID, ulcers and prostaglandins J. Rheum, 1992, Vol 1; (suppl 36) 19: 68-73
  2. Langman, M.J., European J. Rheum, 11(1):13, 1991
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Compassionate Acupuncture and Healing Arts, providing craniosacral acupuncture, herbal and nutritional medicine in Durham, North Carolina. Phone number 919-309-7753.

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One Response to Osteoarthritis and the Side Effects of NSAIDs and Corticosteroids

  1. lumin smith says:

    Osteoarthritis is a degenerative disease that causes the cartilage of the joints to wear down after a period of time. Osteoarthritis Symptoms are often painful and physically debillating for sufferers who have the condition. The disease also affects a patient mentally and emotionally because Osteoarthritis often limits normal, daily activities.

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