Medicine and Supplements

NSAIDs

The most common tool used in modern medicine to treat chronic inflammation is medication. The medicines orthopedic surgeons use most often are non-steroidal anti-inflammatory drugs (NSAIDs). Many of these are familiar to most patients. The oldest NSAID is aspirin. Ibuprofen is the most common and is also known as Motrin or Advil. Naprosyn is also known as Naproxen or Aleve. Meloxicam is known as Mobic. Celebrex is another popular medication. There are many more but in reality they are like Coke and Pepsi. The best one is specific to each patient. They work by decreasing inflammation, which as a result decreases pain. They are also used to decrease fever and prevent blood clots. 25 years ago, if you came to see an orthopedic surgeon, you were likely to be put on 800mg of Motrin three times a day. Now orthopedists are far more cautious with the use of NSAIDs. Like all medicines, NSAIDs have side effects such as gastrointestinal ulcers and bleeding, heart attacks, and kidney disease. This results in some standard rules of how we recommend them. If you are healthy with no risk factors, we may prescribe the reliable 800mg of Motrin or 500mg of Naprosyn for an acute injury but will be cautious with long term use and will ask you to notify your primary doctor so they can keep an eye out for side effects. If you need a long term NSAID, we will be weighing the risk and benefits of the medicine versus your other, perhaps more aggressive, treatment options and will lean towards a daily medicine because it is easier to take on a consistent basis. An example would be a patient whose symptoms are controlled by Mobic is at a lower risk for poor outcome than if we proceeded with surgery such as a joint replacement in many cases. If you are prescribed an NSAID, we will not want you to mix in over the counter NSAIDs during the day because it will increase your risk of side effects.This means if you're prescribed Motrin, do not add in Advil or Aleve during the day.  If your doctor has you on aspirin, we will not want to prescribe you an NSAID because the risk of a bleeding ulcer is concerning. If you have a history of ulcers, heart disease, or kidney issues, we will only recommend an NSAID if your primary doctor agrees. Finally Tylenol is not an anti-inflammatory drug, but it does help with pain. It does not cause bleeding ulcers, heart attacks, or kidney problems so it is generally safe unless you have liver issues or if you are a heavy drinker and potentially have undiagnosed liver issues. 

Corticosteroids

Corticosteroids are another group of medicines used to treat inflammation. An orthopedist will often prescribe this medicine in pill form or as a steroid/cortisone injection. The Medrol dose pack or steroid pack is often used as a treatment of acute inflammation. The goal of a Medrol dose pack is to cure the inflammation. In the short term the side effects are minimal. However, it is not used for chronic inflammation due to side effects related to long term use. If a steroid pack is helpful but the symptoms return quickly, it is usually time for another treatment option rather than repeating the steroid pack. A steroid injection is usually preferred when the site of inflammation can be a small targeted area such as a single tendon or joint due to less systemic side effects. Orthopedists rarely prescribe long term steroids due to significant side effects, but your primary care doctor or a rheumatologist may need to to control the disease process. The most common corticosteroid is prednisone. When your doctor prescribes this for long term use, they are aware of the side effects but feel the risks of the disease process are more than the risk of the medicine. An orthopedist will often refer you to a rheumatologist if they suspect you have an autoimmune disease which may require long term steroid treatment. An autoimmune disease is a condition resulting in an abnormal immune response resulting in chronic inflammation often in multiple body parts. If this is suspected, you will be referred for testing. The most common autoimmune disease is rheumatoid arthritis. Further along in the disease, the diagnosis can be made by physical exam or radiologic studies such as x-rays or MRIs, but early detection requires a blood test. 

Steroid Injections

Cortisone injections are frequently used for treatment of chronic inflammation. When someone has tendinitis or bursitis, injections can often be a cure. The main side effect in tendons is weakening of the tendon. In shoulder tendons, injections are typically successful with good results but physical therapy is often needed to prevent the tendon issue from returning. In the hand, injections are commonly used and have no restrictions on when the patient is able to return to activities. In the elbow, they can be effective, but if you continue repeating the problematic activity, you will often have the symptoms return. You can repeat the injection up to 3 times a year per site but ultimately they will stop working if you are not cured after a few shots. They are used with extreme caution for the quadricep, patellar, and Achilles tendon because even slight weakening of these tendons can result in rupture and potential surgery. Cortisone injections are used in the joints to treat arthritis. When used to treat arthritis, the results are always temporary. When someone injures a mildly arthritic joint, the injection can often be a cure for the acute exacerbation of their symptoms. When someone has a moderately arthritic joint, an injection can help them return to normal activities but will need to be repeated. For a severely arthritic joint, the patient can get up to 3 shots a year (one every 4 months). This is not a cure, but is often an option for someone trying to postpone or avoid a joint replacement surgery. The shots can be painful but it's only for a few seconds. The pain of the injection depends on the part of the body being injected. For example, hand and foot injections are more painful than the bigger joints such as the shoulder or knee. Many pain specialists or rheumatologists will use ultrasound guidance for injections, but most orthopedists do not need this because they are familiar with the anatomy of the joint from years of doing surgery. Certain injections must go deeper for deeper joint such as those in the spine or the hip. A deep injection in the spine or hip usually requires an MRI prior to the injection and will be done under fluoroscopic guidance. The main side effect of injection in the joint is they can weaken the healthy joint cartilage if you get too many. This is the reason the number of injections is limited even if they give great relief. The most common systemic side effects of injections are a temporary increase in blood sugar and facial flushing. The other side effect is you risk getting a shot that does not work. When the shot works the doctor is often the hero, when it does not it can be dissapointing. Patients often ask if it hurts and my standard reply is“it does, but it is not that bad. That said, I'm not about to let you give me one”.

Gel Injections

Another group of injections known as “gel injections”, Viscosupplementation, or Hylaron injections are used in the knee. These can be effective but require approval from your insurance company which can take several weeks, so they are not great for acute pain. These shots work as a lubricant in the knee and ideally reduce irritation from the rough and damaged joint surfaces contacting each other which will ultimately decrease chronic inflammation. Generally, the insurance company determines the brand you will receive but, again, they are all about the same. The main, but rare, side effect is a reaction to the medicine resulting in swelling or increased pain. These injections come in one shot or a series of three shots. They are effective, but if they worked for everyone, no one would need joint replacement surgery.

Topical Pain Relievers

Creams or lotions exist as both NSAIDs and corticosteroids. They can help with minor pain or help take the edge off of moderate pain. Less medicine is absorbed systemically so they have less risk of side effects

Alternative Supplements

The risk of side effects is why doctors are looking at alternatives to medication to treat chronic inflammation and why many patients try to avoid medication entirely when possible. In reality, this is why physicians are giving attention to the other 4 baskets of inflammation because the side effects of improving nutrition, exercise, sleep and stress management are almost nonexistent. There has been an increased focus on some supplements however. Some patients take supplements with Glucosamine and Chondroitin. The data shows some degree of efficacy for patients which means it is reasonable to see if it works for you but do not keep spending your money on it if it is not working . Another popular supplement, turmeric/curcumin, has been found to decrease pain from inflammation compared to placebo, and that it is comparable to Ibuprofen without the side effects. More studies are needed to determine the best dose and the most absorbable form. Some patients take it in pill form and others put a table spoon of the spice in water with some black pepper and chug it down like dirt water. Others put it in tea or just try to cook with it frequently. Other anti inflammatory supplements are fish oil, ginger, resveratrol, spirulina, and Vitamin D. They all likely can help with chronic inflammation with minimal, but not negligible, side effects. However, they all need to be studied more. The issue is you can not patent a naturally occurring substance, so there is not much money to be made selling them and, as a result, not much money is put towards researching them. Hopefully, we will have more data available on supplements in the future, but I encourage you to explore the evidence that exists currently on what may be a viable option you may want to try.