Q: I have osteoarthritis. My doctor recommends NSAIDs over acetaminophen for pain relief. Why? What is the advantage?
A: The answer to your question lies in the type of damage osteoarthritis inflicts.
Osteoarthritis results from the deterioration of cartilage, the tough, flexible tissue that covers the ends of your bones at every joint in your body. The cartilage is a cushion that keeps one bone from grinding against another bone.
As cartilage degenerates, patches of bone become exposed. Those patches of bone start to rub against each other and become irritated. They try to repair themselves, but the repairs are uneven, bumpy, jagged. This further irritates the surrounding soft tissues and causes inflammation.
A key part of arthritis treatment is drug therapy to alleviate pain and inflammation. The first step is usually over-the-counter acetaminophen (Tylenol). Doctors often recommend it first because it relieves mild pain and is easy on the stomach.
But nonsteroidal anti-inflammatory drugs (NSAIDs) are often more effective. That's because they not only relieve pain, but also reduce inflammation. NSAIDs include aspirin, ibuprofen (Advil, Motrin, others) and naproxen (Aleve, Naprosyn).
NSAIDs work by inhibiting the COX-1 and COX-2 enzymes. COX-1 protects the stomach lining from stomach acids and harsh digestive enzymes. COX-2 causes pain and inflammation. NSAIDs relieve pain and inflammation by inhibiting COX-2. But by inhibiting COX-1, they often cause stomach problems, including bleeding and ulcers.
COX-2 inhibitors are a newer type of NSAID. These drugs inhibit only the COX-2 enzyme involved in pain and inflammation; they spare the protective COX-1 enzyme. As a result, they relieve pain as well as the strongest NSAIDs with less stomach irritation.
However, COX-2 inhibitors increase the risk of heart attack and stroke. Only one COX-2 inhibitor, celecoxib (Celebrex), remains on the market.
If you choose a traditional NSAID, ask your doctor about taking it with a stomach-protecting drug. Examples include histamine blockers and proton-pump inhibitors. (Some medicines already combine an NSAID with a stomach-protecting medication.)
Also, don't use an NSAID every day except under the supervision of your doctor. It appears that most of the NSAID drugs, like the one COX-2 inhibitor that remains on the market, very slightly increase the risk of heart attack and stroke when taken regularly.
Finally, don't rely solely on medication. Try other pain-relief strategies such as physical therapy or massage. Strong muscles around a joint can reduce the force with which bone meets bone. Physical therapy increases muscle strength.
Why massage, since the joint is deep inside the body, well away from the fingers of the person performing massage?
Because arthritis in a joint often causes spasm of the muscles around that joint. This is particularly true of arthritis of the hip and knee. Massage can relieve the muscular pain.
I learned this when my right hip developed severe arthritis. While the hip hurt, the pain in many of the muscles of my right leg was worse than the hip pain. Massage helped greatly.
• Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., Second Floor, Boston, MA 02115.