Acetaminophen as well as NSAIDs such as ibuprofen and naproxen are commonly recommended medications to help control pain and improve function related to symptomatic knee osteoarthritis. However, more and more studies are revealing that medications such as ibuprofen are associated with significant side effects such as gastrointestinal bleeding, renal failure, worsening hypertension, and cardiovascular complications; and all of these effects are much more common in seniors and the elderly which unfortunately is also the population most likely to be dealing with osteoarthritis. So is there another option that provides just as much pain relieving power as ibuprofen without all the side effects? The answer is yes but it’s not what you think it’s going to be.
We often tout exercise therapy as a core treatment for anyone with osteoarthritis. And that’s because aerobic exercise helps the joint increase the production of natural lubrication which can then decrease friction inside the joint and prevent inflammation. In addition, strength training helps build up the muscles around the knee to take the pressure of the joint and protect the bones. But these are often seen as long term pain relieving effects that take time to develop.
Well, that notion is now being challenged by this new study. This article published in the British journal of sports medicine compared the therapeutic and pain relieving effects of exercise therapy to acetaminophen as well as NSAIDs such as ibuprofen and naproxen.
This was a network meta-analysis which included 152 randomized controlled trials with over 17,000 participants all with either knee osteoarthritis or hip osteoarthritis. They found that there was no difference in pain relief or functional improvement between exercise therapy and common pain medications such as acetaminophen or NSAIDs at 4 weeks, 8 weeks, and 24 weeks of treatment.
The authors go on to conclude that “exercise has similar effects on pain and function to that of oral NSAIDs and acetaminophen. Given its excellent safety profile, exercise should be given more prominence in clinical care, especially in older people with comorbidity or at higher risk of adverse events related to NSAIDs or acetaminophen.”
In my most recent videos, I’ve actually discussed that daily walking is incredibly beneficial to those with knee osteoarthritis. Walking in general has benefits to all cause mortality, cardiovascular disease, mental health, cognitive function, immune function, weight loss, and more. Specifically for arthritis, walking helps prevent arthritis from getting worse and is associated with better outcomes. Try to get 7500 steps per day for maximum benefits.
Similarly, strength training targeting muscles in the entire lower extremity as well as focusing on treating the muscles around the knee have been shown to significantly reduce pain and improve function related to symptomatic knee osteoarthritis.
What this new study adds is that all the pain relieving effects of exercise therapy occur much faster than what we previously realized and are actually much more profound and comparable to common pain relieving medications.
So does this mean you should never take ibuprofen, naproxen, or acetaminophen ever again? No not necessarily. But before I explain why, let me just say that NSAIDs need to be taken with care. They are not benign and they actually do carry significant health risks in terms of side effects. NSAIDs such as ibuprofen and naproxen are actually listed by the American Geriatric Society as potentially inappropriate medications for the elderly based on evidence-based recommendations. Taking NSAIDs is something that needs to be discussed with your health care provider, especially if you have underlying medical comorbidities such as high blood pressure, kidney problems, GI problems, or heart problems.
With that said, pretty much all health care providers agree that taking NSAIDs for weeks and weeks on end is definitely a bad idea. Longer acting NSAIDs such as naproxen and meloxicam are also much more likely to cause side effects than shorter lasting NSAIDs such as ibuprofen. But now the question becomes can you take them in quick short bursts? Well that’s where you will want the expertise of your health care provider.
Ok so with that out of the way, in an otherwise healthy person, I do tell people that taking the occasional ibuprofen and naproxen is generally safe. In fact, I typically recommend my patients to take a burst at a time. A typical regimen would be 600 mg of ibuprofen three times a day for three days. Take it with food so it doesn’t upset your stomach. This regimen can help decrease pain and symptoms from an acute arthritis flare up so that you can start exercising again. And hopefully once you start moving again, then you will start getting pain relief from the exercise therapy. We really need to start seeing exercise as a prescription, that it does have it’s own pain relieving effects, and that the effects are comparable to common over the counter pain medications.
For all the reasons above, you can see here that exercise therapy and load management continue to be at the top of my list for knee osteoarthritis treatments. NSAIDs are meant to be used sparingly and in short bursts and not more than a few days at a time. They definitely should not be used long term.