Painkillers for rheumatoid arthritis

Photo of a man taking his medicine (PantherMedia / nyul) Anti-inflammatory painkillers and steroids can relieve the symptoms of rheumatoid arthritis. But they don't prevent joint damage. They are suitable for the relief of acute pain, as a temporary treatment until disease-modifying drugs start to work.

Disease-modifying antirheumatic drugs (DMARDs) can reduce inflammation in the body, which prevents joint damage and relieves the symptoms. But it can take several weeks before they start working. Until that happens, the symptoms of rheumatoid arthritis can be relieved with painkillers and steroids.

What are the pros and cons of non-steroidal anti-inflammatory drugs (NSAIDs)?

NSAID painkillers can relieve pain in the joints. Examples of these drugs include:

  • celecoxib
  • diclofenac
  • etoricoxib
  • ibuprofen
  • naproxen

Research has found that they relieve symptoms in about 15 out of 100 people.

The possible side effects of anti-inflammatory painkillers include:

  • An upset stomach: in about 3 out of 100 people.
  • Ulcers and bleeding in the stomach: in up to 2 out of 100 people who take NSAIDs for a year.
  • Cardiovascular (heart and blood vessel) disease: in up to 1 out of 100 people who take NSAIDs for a year.

The risk of side effects and complications will depend on various factors, such as the exact medication and dose used. Celecoxib and etoricoxib are less likely to cause stomach problems than other NSAIDs are.

With the exception of acetylsalicylic acid (the drug in medicines like Aspirin), NSAIDs can somewhat increase the risk of cardiovascular diseases such as heart attacks. This risk is lowest when using naproxen, so naproxen is the most suitable NSAID for people who have both rheumatoid arthritis and a cardiovascular disease.

When used over the long term, NSAIDs can lead to stomach ulcers. These are usually felt as a pain in the upper abdomen. The pain is particularly noticeable just after eating, when the stomach produces more acid. Sometimes stomach ulcers don't cause any symptoms, and people only find out that they have one if they have serious complications such as bleeding in the stomach.

Who has a higher risk of complications?

Stomach ulcers or bleeding are more likely to occur in people who

  • are over 65 years old,
  • have other serious diseases, especially gastrointestinal conditions like Crohn’s disease or ulcerative colitis,
  • have already had gastritis (an inflammation of the stomach), a stomach ulcer or stomach bleeding,
  • have an infection with Helicobacter pylori bacteria,
  • drink a lot of alcohol,
  • take blood-thinning heart medicines, for example anticoagulants like warfarin or acetylsalicylic acid,
  • take a selective serotonin reuptake inhibitor (SSRI) antidepressant,
  • take corticosteroids (“steroids”), or
  • take several anti-inflammatory painkillers at the same time.

NSAIDs can sometimes be a problem for people who have kidney disease too.

How can side effects be avoided?

NSAIDs should only be used when needed, and not over a long period of time – in other words, only to relieve acute pain. It's important to use the lowest dose possible, and not to exceed the maximum daily dose. If you're considering using NSAIDs, it's best to talk to your doctor about the most suitable medication and dose.

The risk of complications affecting the gastrointestinal tract can be lowered considerably by taking NSAIDs together with medicine designed to protect the lining of the stomach. These include, in particular, proton pump inhibitors like omeprazole or pantoprazole.

Alternatively, diclofenac or ibuprofen can be applied to the painful joint in the form of a cream or gel. The risk of side effects is then much lower than it is if you take tablets.

Does acetaminophen (paracetamol) help in rheumatoid arthritis?

The painkiller acetaminophen (paracetamol) only has a weak anti-inflammatory effect. Research has shown that it hardly helps in the treatment of rheumatoid arthritis, and clearly relieves the pain less effectively than NSAIDs do.

If you take acetaminophen anyway, it's important to use it correctly. Higher doses can lead to liver and kidney damage. So adults shouldn't take more than 4 grams (4,000 mg) per day according to the package insert. This is the amount in, for example, 8 tablets containing 500 milligrams of acetaminophen each. Waiting at least six hours between two doses is also recommended. So two 500 mg tablets of acetaminophen every six hours over one day would be the maximum allowed amount.

When does it make sense to use steroids?

Steroid medications (glucocorticoids) such as prednisolone help to reduce pain and swelling in the affected joints. They start working fast and have a stronger effect than NSAIDs do. They can help to cover the stretch of time until the basic therapy with disease-modifying drugs starts working. They can also be used for the temporary treatment of rheumatoid arthritis flare-ups. But people are advised not to use steroids for longer than 3 to 6 months. One reason for this is because the medication might become less effective over time.

Steroids can also have a number of serious side effects when taken over longer periods of time. These include an increased risk of bone fractures and infections. People who have osteoporosis can combine steroids with things like calcium and vitamin D supplements to help protect their bones. If treatment with steroids is stopped too suddenly, the symptoms might actually get worse. So it's important to gradually reduce the dose instead.

Steroids can be injected directly into individual joints to target the worst affected joints. This reduces the risk of side effects that affect the whole body. But local side effects, such as an infection in the joint, are still possible. Unfortunately there's a lack of good-quality research on the advantages and disadvantages of these steroid injections.