Osteoarthritis (OA) is the most common of all joint diseases, affecting more than 30 million Americans. In the next few decades, the number of people suffering with osteoarthritis is expected to skyrocket, as people are living longer and the percentage of the population that is overweight continues to increase. A common treatment intervention for osteoarthritis is anti-inflammatory medications (NSAIDs), such as aspirin, ibuprofen, and naproxen. Given their widespread use in the management of OA, you would think there would be an abundance of scientific evidence suggesting these drugs are actually useful. This is not the case. In a 6-year study of nearly 1,700 people with hip and knee arthritis, researchers from the Netherlands determined that individuals who routinely took NSAIDs for pain management had a 240% increase in the development of hip arthritis and a 320% increase in the development of knee arthritis compared to individuals who rarely used these drugs (1). The authors state, “Whether this occurs because of a true deleterious effect on cartilage or because of excessive mechanical loading following pain relief remains to be investigated.” Putting aside the accelerated development of arthritis, routine use of NSAIDs to manage joint pain significantly increases the risk of GI bleeds, hypertension, coronary artery disease, atrial fibrillation, and even congestive heart failure (2). Disturbingly, a recent paper found that 14% of high school and college football players take nonsteroidals daily despite the proven health risks (2). 

To reduce potential side effects associated with corticosteroid use, physicians frequently prescribe short-term oral corticosteroids (i.e., less than 2 weeks) with the belief that the complication rates will be extremely low due to the short duration of treatments. To test this theory, researchers from Taiwan looked at 2.6 million people who received a short steroid burst during the study period (3). These were all low risk people with an average age of 38. Regardless of their overall health and young age, the rates of GI bleeds, sepsis and heart failure were alarmingly high, with 2.7% of the treated population developing GI bleeds, and 1.3 per thousand suffering heart failure. The authors of this study acknowledge that these numbers may represent an underestimation, because they excluded people over the age of 64, who are high-risk for complications following corticosteroid interventions. 

As if taking oral NSAIDs for the management of joint pain isn’t bad enough, another common treatment intervention for osteoarthritis is to inject corticosteroids directly into the arthritic joint. In spite of the popularity of this treatment intervention, the relative safety of intra-articular corticosteroids has not been adequately studied. In 2019, doctors from Boston University injected 459 patients presenting with hip and knee arthritis with intra-articular corticosteroids (4). Over the next 2 to 15 months, 8% of these patients developed serious complications, the most common being accelerated joint destruction (Fig. 1). 

While an 8% percent complication rate is high, the authors only followed up on 241 of the 459 individuals injected, so the complication rates were most likely appreciably higher. The authors of this study were surprised by the high prevalence of adverse events, but a recent study of 70 patients by Simeone et al. (5) showed the 44% of patients receiving intra-articular corticosteroid injection had accelerated progression of osteoarthritis and a shocking 17% developed articular surface collapse (Fig. 2). Note that the Simeone et al. (5) study was controlled in that the authors compared outcomes between 2 groups with similar degrees of arthritis: one group received the intra-articular corticosteroid, and the other group did not. In the group that did not receive the injection, 24% had radiographic progression of arthritis but only 1% suffered joint collapse. Although the exact mechanism for adverse events remains unclear, there is some evidence that corticosteroid injections, especially when combined with an anesthetic, can be toxic to cartilage (6).

Rather than bombard an arthritic joint with potentially harmful NSAIDs, a safer approach would be to encourage regular exercise (which has been proven to reduce pain) and recommend simple dietary changes. In a 2013 study evaluating the effectiveness of either diet, diet plus exercise, or exercise alone in the management of osteoarthritis in overweight and obese elderly individuals, nearly 90% of the 454 people who began this 18 month study had significant reductions in pain and achieved more than 10% loss in body mass (7). Not surprisingly, the combination of diet and exercise achieved the best outcomes, as these individuals had less pain, better function, faster walking speeds, and a better self-reported quality of life than the diet alone group. The diet and exercise group also had greater reductions in interleukin-6, which is a marker of systemic inflammation that correlates strongly with the progression of osteoarthritis. The bottom line with all of these studies is that the most effective way to manage osteoarthritis is not with medications, but with diet and exercise. While many people would argue that diet and exercise interventions are too difficult to follow and compliance is low, it still has to be presented as an option, as the risks associated with pharmacological management are too great.

References:

1. Reijman M, et al. Anti-Inflammatory drugs and radiological progression of osteoarthritis? The Rotterdam Study. Arthritis and Rheumatism. 2005;52;3137-42.
2. Tso J, et al. Nonsteroidal anti-inflammatory drugs and cardiovascular risk in American football. Med Sci Sports Exerc. 2020.
3. Yao T, et al. Association between oral corticosteroid bursts in severe adverse events. Ann intern Med, July 7, 2020.
4. Kompel A et al. Intra-articular corticosteroid injections in the hip and knee: perhaps not as safe as we thought? Radiology 2019;293:656–663.
5. Simeone F, et al. Are patients more likely to have hip osteoarthritis progression and femoral head collapse after hip steroid/anesthetic injections? A retrospective observational study. Skeletal Radiol 2019;48:1417–1426.
6. Breu et al. The cytotoxicity of bupivacaine, ropivacaine, and mepivacaine on human chondrocytes and cartilage. Anesth Analg 2013; 117:514.
7. Messier S, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: The IDEA randomized clinical trial.  JAMA  2013;310:1263-1273.