Medicine For People!

October 2018

Rheumatoid Arthritis
By James Heilman, MD - Own work, CC BY-SA 3.0
https://commons.wikimedia.org/w/index.php?curid=11110471

Topical Anti-inflammatory Medication

Table of Contents

  • Joint Inflammation
  • Topical Medication
  • Appendix: Adverse Effects of NSAIDs
  • Appendix: Low-Cost Alternatives to Pharmaceutical Products

Joint Inflammation

Inflamed joints can be deep or superficial. An inflamed large joint, such as a hip, usually requires an oral anti-inflammatory for pain relief. Without ongoing pain, a person can remain up on their feet and moving. For healthy people, the beneficial side effects of normal activity (including optimal blood sugar, better mental function, lower risk of falls, improved sleep, etc.) outweigh the rare adverse side effects of the anti-inflammatory medication.

You can read more about the inflammatory process and treatment options here

Thinking further, if you don't need to saturate your whole body with the pharmaceutical to get the job done, and you can put it on your skin, you lower your risk of adverse effects from the drug.

Topical Medication

Topical anti-inflammatories get the medication directly to the scene of the crime without running it through your entire body and its various organs. There are several options.

First though, let me introduce the initials NSAID (pronounced "In-sed"). This stands for Non-Steroidal Anti-Inflammatory Drug. The steroidal anti-inflammatory drugs include prednisone, dexamethasone, and various others. These are powerful drugs and generally reserved for more serious situations.

Decades ago a class of anti-inflammatory drugs was introduced that were not steroids. These include ibuprofen, naproxen, diclofenac and others, and all have a much kinder side-effect profile than the steroidal drugs. Aspirin also falls into this class. These are the NSAIDs and the topic of this newsletter.

For small joints such as those in the hands and fingers, we can apply an NSAID as a cream or gel. The least expensive and most available product on the market is diclofenac topical 1% gel, costing about $45 for 3 ounces with some careful shopping.

For the knee, the generic version of branded Pennsaid, a 1.5% topical diclofenac, costs about $50 for 5 ounces.

These products are also helpful for chronic pains, strains and sprains, though these conditions come in such variety that success is not guaranteed every time.

These topical formulations provide higher anti-inflammatory doses in the areas to which they are applied than you can obtain with an oral medication, though it can take several days to reach these more beneficial levels.

Inflammatory pain in a joint can occur in the joint itself or in the tissues around the joint. For this reason, people experience differing degrees of relief from these medications.

Appendix: Adverse Effects of NSAIDs

These topical anti-inflammatories are much safer than the same medications by mouth. While we are on this subject however, let me address the potential side-effects of oral NSAIDs. People ask me about these frequently.

First, several drugs in this class have been introduced into the market and later pulled because of side effects. The NSAIDs that you find on your pharmacy shelf have landed there only after decades of safe use.

Second, risk is lower when used according to the label and with intermittent or infrequent use. To put some numbers on the risk, and considering those NSAIDs which have stood the test of time, liver damage occurs in about 1 person per 65,000 exposed individuals. When we consider prescription strength NSAIDs (doses higher than those listed on the label of your over-the-counter NSAID), hospitalization for kidney failure happens to about 1 person per 400 years of use.[1] People can develop bleeding ulcers and about 30 years ago one of my patients landed in the hospital with a bleeding ulcer requiring blood transfusions following long-term heavy use of NSAIDs.

Never have I seen such a medication damage a healthy liver or kidney. The operative word here is "healthy." If your laboratory tests show diminished kidney function, the first thing your doctor is going to do is tell you to stop using NSAIDs.

Here are some other important points:

  • Take only one NSAID at a time
  • Longer term use of NSAIDs can make you retain fluid leading to swollen legs and higher blood pressure

Side effects from oral NSAIDs occur more often in people who are overweight [2], consuming too much alcohol, or taking certain other drugs such as anti-hypertensives, anti-coagulants, anti-depressant medications, and others. If your doctor is prescribing medication for an on-going problem, let her know if you are taking NSAIDs on a more-than-occasional basis.

Appendix: Low-Cost Alternatives to Topical Pharmaceutical NSAIDs

Until very recently, there were no inexpensive pharmaceutical versions of topical NSAIDs. If at some point in the future, the pharmaceutical versions become excessively costly, here are some alternatives that we used when the prescription drugs were under patent and cost over a hundred dollars.

The most reliable substitute was and is the NSAID ketoprofen, prepared by our local compounding pharmacist, Don Hoglund at Don's Pharmacy. Before the inexpensive generics arrived, his product was less than half the cost of the branded pharmaceutical product.

Homemade recipes included:

  • Crush an aspirin tablet into glycerin and apply to painful joints. Let me give credit for this to our late local neurologist Jack Hutton, who used it with success for certain patients with headache.
  • Squeeze the contents of a 200 mg ibuprofen gel into ¼ teaspoon of glycerin and apply to inflamed joints of the hand. This was brought to my attention courtesy of retired music professor and local impresario Alan Rawson, D.M.A. Alternately, says Rawson, he will apply the ibuprofen gel directly and spray DMSO mist over the treated joint.
  • DMSO stands for dimethyl sulfoxide. This wood solvent helps push substances through the skin and has been extensively studied with different NSAIDs. Mix this with any pharmaceutical NSAID available in a gel form and apply it to the painful joint. The pharmaceutical industry limits DMSO to no more than 45% of the total volume of the topical solution. [3] Excessive DMSO can irritate the skin.

NSAIDs in gel form include ibuprofen, diclofenac (available as Voltaren), and naproxen sodium. Others may become available in the future.

Given the current cost of topical NSAIDs, most people will have no reason to prepare their own. If you do, be sure to obtain pharmaceutical grade DMSO and wash your hands and the painful area before use.

Endnotes

[1]Nonsteroidal Antiinflammatory Drugs and Acute Renal Failure in Elderly Persons, Marie R. Griffin Aida Yared Wayne A. Ray. American Journal of Epidemiology, Volume 151, Issue 5, 1 March 2000, Pages 488–496 (Note to Douwe: is Antiinflammatory actually misspelled in the title of the article?)

[2]Non-steroidal anti-inflammatory drugs: What is the actual risk of liver damage?. World J Gastroenterol. 2010;16(45):5651-61. (Note to Douwe; this is a larger font.

[3]Diclofenac sodium topical solution with dimethyl sulfoxide, a viable alternative to oral nonsteroidal anti-inflammatories in osteoarthritis: review of current evidence" Philip Fuller, Sanford Roth Journal of Multidisciplinary Healthcare 2011:4 223–231 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141840/pdf/jmdh-4-223.pdf

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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.