OTC OA Relief for Athletes

By Edward H. Nessel, R.Ph, MS, MPH, PharmD

Arthritis is the physiological result of longstanding inflammation. It occurs when the cartilage between joints breaks down, and these joints undergo the inflammatory process and grow stiff.

Calcium is often deposited by the body in reaction to arthritis syndrome. This calcium is easily seen on x-rays as opaque deposits throughout the affected structure. It often interferes with proper functioning by standing in the way of designed movement. The patella, for instance, contains a groove that ordinarily serves to keep movement in the knee functioning smoothly and, indeed, as one of the most efficient mechanisms in the human body. But if arthritis develops, and calcium is deposited in this groove, movement of the leg at the knee can be quite distressful and debilitating.

Osteoarthritis is the type experienced by athletes most often. Wear and tear that comes with intensive overuse, strong physical trauma, and the simple aging process all contribute to the increasing dysfunction of a normally smooth-moving pain-free joint.

The joints and synovial fluid
Since the joints are where bone moves against bone to allow the body to shift position in different plains, they are lined with smooth cartilage protecting each end that enters the joint. Most activities against gravity (including walking, running, weightlifting, and ball sports) produce various amounts of shock to the body which is absorbed by the cartilage and the lubricating fluid of the various joints directly involved with the movement, known as synovial fluid.

One of these lubricating substances found in between and all around the joint cartilage is hyaluronic acid, which brings along glucose for metabolic energy as part of its molecule. The rest of the synovial fluid carries oxygen to the joint and removes carbon dioxide and metabolic waste products. The synovial fluid has a unique liquid property in that it can have its viscosity increased upon joint compression for extra lubricating protection and go back to lessened viscosity when joint compression is relieved.

Each of the joints in the human body contains synovial fluid, which is produced within the thin layer of tissue lining the joints called the synovium. The synovium is the main place where inflammation occurs in patients with arthritic joint disease.

In addition to inflammation, pain, and restricted movement, the skin around the affected joint may have a tell-tale reddish tinge and feel warm. Healthy joints should not bring pain upon movement. There should be no "marker" of distress when executing joint activity. If pain becomes long-standing and is reproducible upon utilization of the same joint, it is considered chronic arthritis.

Treatment with non-prescription medication and devices
Arthritis cannot be cured. Once in place, it becomes a permanent resident of the affected joint. So what treatment modalities can be instituted without bringing a physician into play? First and foremost, exercise caution and common sense if a physician, pharmacist, or physical therapist is not consulted.

Thermotherapy. Microwavable wraparound products that provide moderate to moderately-strong heat to affected areas are one effective treatment for osteoarthritis. An example of an advanced version of this treatment option is the ThermaCare family of HeatWraps, which are labeled for arthritis use.

These wraps incorporate cells made of iron, water, and salt. Upon tearing open the wrap, a continuous low-level heat is generated by the iron being oxidized to the air with the salt and water creating a sustained 104 degrees within 30 minutes and lasting for about eight hours. The wraps come shaped for different body parts and have a sticky side that adhere them to the applied skin. It should be removed after the eight-hour dosage to prevent skin damage especially in the young, elderly, and those suffering debilitating diseases like diabetes and psoriatic conditions. It should not be used if rubefacients (see below) are applied first.

External analgesics. Rubefacients (heat rubs such as oil of wintergreen) are a class of therapeutic topical treatments known as counterirritants. They are for external use only and should not be exposed carelessly to the eyes, nose, and mouth. They are labeled to provide temporary relief of arthritis in addition to other painful musculoskeletal conditions. This class of product can produce redness (e.g., methyl salicylate, turpentine oil), or not (e.g., capsicum, capsaicin). There are also those that produce cooling sensations (e.g., camphor, menthol, eucolyptol), and those that vasodilate (e.g., histamin, methyl nicotinate).

Their actions are not tied to direct local pain-killing as with topical anesthetics like benzocaine or pramoxine. Rather, the effects they produce on upper skin layers are believed to distract patients from the pain arising from lower areas that they cannot reach. These products must not be applied to wounded or damaged skin and should never be bandaged or wrapped after application.  As noted above, absolutely no source of heat is to be added to these applications. Product examples are BenGay (camphor, menthol, methyl salicylate), Icy Hot (menthol, methyl salicylate), and Mineral Ice (menthol).

Drug-infused topicals. There now exist over-the-counter gels and creams that carry active NSAID ingredients such as ibuprofen into deeper tissue where applied. These drugs can provide impressive relief against any chronic pain of osteoarthritis. The listed side effects from the gastrointestinal tract are reduced since these medications do not have to be absorbed from oral administration. But they carry with them the cautions of how the NSAIDs act once absorbed.

Internal analgesics with no anti-inflammatory properties. These are often the first choice of treatment but also carry the strongest usage warnings. Acetaminophen is extremely popular and found in many products by itself and in combination with other drugs. It works well to address mild to moderate pain but does not provide anti-inflammatory activity. The strongest dosage comes in a 650-mg extended release tablet offering eight to 10 hours of relief. It can be taken along with NSAIDs for a synergistic effect since it has a different area of activity, but taking this product absolutely obviates the drinking of alcohol. The last few years have brought to light the potential for severe hepatic (liver) toxicity mixing the two even in moderate amounts.

Acetaminophen should not be taken together if found in more than one product, nor taken in amounts greater than the maximum recommended dosage throughout the day. The damage to the hepatic tissue can be quite extensive and can progress to a fulminating type of inflammation with very serious consequences.

NSAIDs. Ibuprofen and naproxen have close to the same uses and warnings. They are members of the same class of medication (NSAIDs) with moderate differences in dosage, effects at the tissue level, and potential for danger. These are the two most popular of the formerly prescription-only, now OTC, products available. The adult concentrations of these products carry the labeling for use with arthritis.
They also carry a severe allergy warning especially if the patient already shows an existing sensitivity to aspirin, listing the usual visual and auditory suspects such as: hives, facial swelling, asthma, wheezing, shock, skin reddening, rash, and blisters.

Caution: Anti-inflammatory power. These NSAIDs can produce severe stomach bleeding which can increase in severity and incidence: in patients over 60; if stomach ulcers are part of the patient's history; if the patient has bleeding problems from being on an anticoagulant; is taking corticosteroids or other NSAIDs from other prescription or OTC products; has three or more alcoholic drinks per day while on these medications; or takes these drugs longer than labeled directions indicate. Repeated heartburn or acid reflux are conditions that can develop and need careful monitoring if you are taking these medicines on a prolonged basis.

Therapeutically, it has been shown that naproxen has better penetrating properties into inflamed tissue than ibuprofen. Because of this, it is considered the better of the two products for treating persistent arthritis pain and inflammation. But, because of this extra physiological activity, it also presents with the possibility of producing more gastric irritation. In some patients, naproxen can produce drowsiness which adds another caution while driving or handling potentially dangerous machinery. Logic would dictate first testing the drug in a safe environment.

This class of drugs, over the years, has shown to be the number one cause of kidney failure in the U.S. due to its inherent pharmacologic activity against kidney function with extended use. Being prostaglandin inhibitors—which is what we are looking for to produce the dramatic anti-inflammatory activity—one of the listed and feared side effects of NSAIDs is their ability to decrease blood flow and, thus, tissue repair to the stomach lining and kidneys. A relatively safe and effective regimen is five days on, two days off (drug holiday) with evaluation of presumed effect.

A second bout of medication may be tried if no untoward effects supersede the intended benefit. Pregnancy and breastfeeding provide for more cautionary consideration. Under no circumstances should anyonein the last trimester of pregnancy be taking this class of medication due to its ability to accelerate the cascade of events leading to birth.

With the freedom provided by the FDA several years ago to allow OTC purchases of NSAIDs comes the corresponding need for precaution to help prevent the sometimes debilitating and even dangerous side effects of their usage.

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