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Osteoarthritis Osteoarthritis is the most common form of arthritis affecting almost 50% of all people over 60 and almost everybody over the age of 80. It is sometimes called "wear and tear" or degenerative arthritis. Osteoarthritis occurs when the cartilage that covers the end of each bone in a joint starts to break down and wear away, leaving the ends of the bones unprotected. This affects the gliding surface of the bones in the joint and as a result they become painful and difficult to move. After a while, the joint can lose its shape and the bone underneath thickens and grows out the sides, further reducing movement. The large weight-bearing joints (knees, hips and spine) are most often affected, although osteoarthritis can also affect the ankles, neck, hands, lower back, base of the toes, and, as a result of injury or stress, the wrist, elbow, shoulder or jaw. Osteoarthritis is caused by a combination of factors, such as aging, genetic defects in joint cartilage, joint injury, joint stress or overuse through sports or certain occupations, and being overweight. There is no one specific cause. Symptoms Osteoarthritis is often very mild and some people may not realise they have it until an x-ray reveals joint changes. Symptoms tend to start in middle age and morning stiffness in a joint (lasting less than 30 minutes), or a deep ache in a joint which is hard to localise, may be the only initial sign. Twinges of pain may be experienced in older people which tend to be relieved with rest and warmth. People with more pronounced osteoarthritis are likely to have a more persistent pain that increases with use and decreases with rest. Other symptoms include: • stiffness in a joint when the joint has been rested • swelling of the joint caused by an increase in synovial fluid production • bony growths (Heberden's nodes) in finger joints – more common in women TREATMENT OPTIONS Category Examples Comments Simple analgesics Oral non-steroidal anti-inflammatory agents (NSAIDs) Combination analgesics Topical non-steroidal anti-inflammatory agents (NSAIDs) Rubefacients (‘heat’ rubs) Other topical applications Natural / herbal products / supplements [GENERAL SALE] eg, paracetamol (Panadol range, Paracare) [PHARMACY ONLY MEDICINE] eg, Panadol Osteo* [GENERAL SALE] eg, ibuprofen 25s (Advil, Nurofen), naproxen (Sonaflam) [PHARMACIST ONLY MEDICINE] eg, diclofenac 25mg (Voltaren Osteo Tabs, Voltaren Rapid 25) [GENERAL SALE] eg, ibuprofen + paracetamol (Maxigesic [16], Nuromol [12]) [PHARMACY ONLY MEDICINE] eg, ibuprofen + paracetamol (Maxigesic [50, 100], Nuromol [24, 48]) [PHARMACIST ONLY MEDICINE] eg, ibuprofen + codeine (Ibucode Plus, Nurofen Plus) paracetamol + codeine (Panadeine, Panadeine Extra) [GENERAL SALE] eg, ibuprofen (Nurofen Gel), diclofenac (Voltaren Emulgel, Voltaren Osteo Gel 12 Hourly*) [PHARMACY ONLY MEDICINE] eg, etofenamate (Rheumon Gel) [GENERAL SALE] eg, Deep Heat range, Ice Gel, Tiger Balm range [GENERAL SALE] eg, capsaicin (Zostrix*), Anti-Flamme Creme, AntiFlamme Extra Avocado-soybean unsaponifiables (ASU), bromelain, chondroitin, fish oil, folic acid, glucosamine, green lipped mussel, turmeric (eg Turmeric Extra Strength*) Regular paracetamol, two tablets (1g) three or four times daily, is the first choice of treatment for mild-to-moderate osteoarthritis. In many cases regular dosing is more beneficial than taking only when the pain is bad. Maximum dosage of 4g/day may need to be reduced in the elderly. Osteoarthritis is not normally an inflammatory condition but occasionally when there is inflammation a NSAID may provide added benefit to simple analgesia. Ibuprofen is the NSAID least likely to cause stomach irritation. NSAIDs may not be suitable for people on certain other medications or with some medical conditions (eg, asthma, kidney disease – see Refer to Pharmacist). Advise customer to stop taking if stomach upsets, increased bruising or prolonged bleeding occur. Stronger NSAIDs are available on prescription. See Reference Section, OTC Medicines – Precautions. Simple analgesics (eg, paracetamol) should be tried first. Warn customers that codeine is an addictive substance and should not be used for more than three days at a time. Constipation or drowsiness may also occur. Monitor sales and be alert for any customers who may be misusing codeine-containing preparations. NSAIDs may have gastric side effects, particularly long term. See Reference Section, OTC Medicines – Precautions. These treat the body’s inflammatory reaction to injury and reduce pain. These are usually effective at relieving localised muscle aches or pains. Do not apply to broken skin or near the eyes or mucous membranes. Wash hands after applying. Do not use under sealed dressings. May, rarely, cause the same adverse effects as oral NSAIDs. Similar care and consideration before use is recommended. Cause blood vessels in the treated area to open and create a sense of warmth, which masks the sensation of pain. Capsaicin reduces levels of a chemical called substance P, which helps transmit pain impulses to the brain. Has been used to relieve pain in osteoarthritis but may take up to four weeks for an effect. Burning or tingling may occur briefly when applied to the skin. Anti-Flamme helps to stimulate blood flow and has an anti-inflammatory and analgesic action. ASUs help with pain and stiffness of osteoarthritis and may delay progression. Glucosamine appears effective. Evidence for chondroitin has not been consistent. Turmeric is reported to have a natural anti-inflammatory effect. Products with an asterisk have a detailed listing in the Osteoarthritis section of OTC Products, starting on page 253. Targeted Action to relieve joint pain Page 114 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION over 40. With the progression of osteoarthritis, symptoms become more severe. Inflammation is more common in advanced disease and the joint may feel hot and inflamed. Osteoarthritis may come and go, and some people identify particular times when the pain is worse, eg, in damp, cold or humid weather. Initial assessment When customers say they have “arthritis”, try and establish if they are talking about osteoarthritis or rheumatoid arthritis. Rheumatoid arthritis is a chronic inflammatory autoimmune condition affecting multiple joints, as well as organs body wide, which is treated by a doctor. Paracetamol is the safest long-term medicine for pain relief, and should be tried first. Heat rubs and other topical applications may also help. Refer anybody wishing to take a NSAID long-term to a pharmacist, as well as those with "yes" answers to the Refer to Pharmacist questions. Treatment The aim of treatment is to control pain, maintain physical activity and mobility and limit further injury. Although treatment cannot reverse the changes that have already taken place in the joints, pain-relieving medicines can help the symptoms and make it easier for people to get out and about. Always encourage customers to seek medical advice early for a full assessment and discussion of all treatment options. Non-pharmacological therapy A properly designed exercise programme is considered the most effective nonpharmacological treatment for osteoarthritis. Excercise helps to keep joints moving and reduce overall pain, improve flexibility and increase fitness. Evidence also supports acupuncture as a treatment for osteoarthritis of the knee. Many communities offer exercise programmes just for people with arthritis such as: »» gentle movement to music classes or t’ai chi »» walking groups »» water aerobics, hydrotherapy or swimming classes. The ultimate treatment for osteoarthritis is joint replacement. However, hip and knee replacements have a limited life – about 15 years – before another replacement is required. Replacement is considered only when joint destruction and pain is severe. The improved mobility and quality of life after these operations is often dramatic. Several complementary products claim to help with the symptoms of osteoarthritis. Controversy exists regarding the effectiveness of many of these products; however, they may benefit some individuals and are often worth a trial. Refer to PHARMACIST The following questions aim to identify customers who would benefit from further input from a pharmacist. Your initial assessment may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the person have any other health conditions (eg, heart or lung problems, diabetes, is pregnant or breastfeeding)? • Does the person take any other medication or complementary therapies, either prescribed by a doctor or bought from a shop or supermarket? • Is the pain severe, burning or interfering with movement? • Was the pain caused by trauma or did it start suddenly? • Is there any back pain? • Does the joint look red or does the person feel unwell? • Is the person young (under 40) or elderly? • Has there been stiffness, pain or swelling for more than two weeks? • Does the joint feel unstable or like it is about to give way? • Is there any creaking or a cracking sensation with movement? • Does the person have any allergies to medicines? these joints. • Weight control reduces the load on joints (see Weight Loss). • Heat may be useful before exercise and ice packs after exercise. • Special aids to help with everyday life, eg, opening jars, turning on taps, putting on stockings and picking up objects, are available from some pharmacies and Arthritis New Zealand, see Support Groups, page 212. • Arthritits New Zealand also delivers regular information sessions in some main centres New Zealand-wide (see for more details). • Medicines and their dosage should be reviewed every two to three months because the severity of pain may increase or diminish. Advice for customers • If pain worsens or continues longer than two to three days, see a doctor. • Supportive footwear will help protect joints. See an orthotics expert. • A walking stick for osteoarthritis of the knee and hip helps reduce stress on ¤ No systemic side effects. 1,2 ¤ No drug-to-drug interaction. 2 ¤ In monotherapy Zostrix ® reduces pain by up to 50% and 80% of sufferers experience pain relief. 1 ¤ In combination therapy, Zostrix ® provides up to 33% more pain relief in addition to the analgesia achieved with oral NSAID’s and Paracetamol alone. 2 Ref 1. Altman RD et al. Capsaicin Cream 0.025% as Monotherapy for Osteoarthritis: A Double-Blind Study. Seminars in Arthritis and Rheumatism 1994; 23 (6): 25–33. 2. Deal CH et al. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther 1991: 13 (3): 383–395. AFT Pharmaceuticals, Auckland. TAPS 1733HA. Page 115

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