Jul
5
Topical NSAIDs
Americans have been deprived of an arthritis treatment that is widely available all over the world. Topical NSAIDs (gels, creams, and sprays) are very popular with patients and physicians in Europe, Australia, Canada, New Zealand, and dozens of other countries, but they are virtually ignored in the United States. The very same drugs (diclofenac, ibuprofen, ketoprofen, ketorolac, piroxicam, etc.) that cause so much mischief
PPI CAUTION
“Although there seems to be a general agreement among gastroenterologists that proton pump inhibitors should be prescribed to high-risk patients taking low-dose aspirin, 91 such a strategy has not been widely adopted because of a lack of definitive evidence to support it.”92
—Carlo Patrono et al., The New England Journal of Medicine, 2005
when taken orally can be applied to the skin with little, if any, risk of stomach ulcers, kidney problems, heart attacks, strokes, or other systemic complications. Except for aspirin-like compounds (salicylates) found in OTC products like Aspercreme, BenGay, Myoflex creme, and Sportscreme, you will not find topical NSAIDs on pharmacy shelves in the United States. That’s because the FDA has never approved these formulations for topical use.
How effective are topical NSAIDs for relieving the pain and inflammation of arthritis? Over the years there have been dozens of clinical trials of such products for both temporary (acute) discomfort and longer-term (chronic) treatment. 3 One review of 26 double-blind, placebo-controlled trials involving 2,853 patients concluded that “topical NSAIDs were effective and safe in treating acute painful conditions for 1 week.”94
Okay, okay! We hear you: “One week, big deal.” Another review examined 14 double-blind, placebo-controlled trials including almost 1,500 patients. The conclusion: “Topical NSAIDs were effective and safe in treating chronic musculoskeletal conditions for 2 weeks.”" That’s a little better, but still not a long-term solution. One sour note comes from the thorough and objective Cochrane Library. The reviewers for this organization analyze all available evidence, published and unpublished, and provide their assessment of various treatments. This 2004 review looked at studies of use of topical NSAIDs for longer than 2 weeks and determined that “after 2 weeks there was no evidence of efficacy superior to placebo. No trial data support the long-term use of topical NSAIDs in osteoarthritis.”96
Based on this summary we would be inclined to suggest that topical NSAIDs be used for 2 weeks or less to relieve an acute arthritis flare-up. On the brighter side, there are now four newer clinical trials of use for 3 to 12 weeks. 97,98 Investigators specifically looked at osteoarthritis of the knee. In each study, diclofenac (Pennsaid or Voltaren Emugel) was superior to placebo in providing relief, with only “minor local irritation and no significant systemic adverse events.”99, 100 In a 12-week head-to-head comparison of oral diclofenac with topical diclofenac (Pennsaid Lotion), their effectiveness was comparable. But side effects like nausea, indigestion, stomach pain, and liver damage were much more likely to occur with the oral NSAID.101
Pennsaid Lotion is interesting because the formulation relies on DMSO (dimethyl sulfoxide) to help get the drug through the skin and into the area of the joint where pain relief is desired. DMSO is a solvent that is uniquely able to penetrate the skin and carry medications with it. We have long wondered why drug companies were not using DMSO to facilitate absorption. Now the makers of Pennsaid have done just that.
So, how can you get topical NSAIDs? If you were in Australia you could purchase products like piroxicam (Feldene Gel), ibuprofen (Nurofen Gel), ketoprofen (Orudis Gel), and diclofenac (Voltaren Emulgel) over the counter without a prescription. At this time that is impossible in the United States. Nevertheless, it is possible to purchase oral ibuprofen and ketoprofen over the counter. That means a compounding pharmacist (one who mixes raw ingredients into finished products) can legally purchase ibuprofen or ketoprofen powder, make a cream or a gel,
sell
and it to you without a prescription.
An alternative would be to shop online for one of the brands mentioned above. Since they are nonprescription in many countries, you may be able to purchase them and not have US Customs give you any problems. One final option, and our number one recommendation, is to have a US physician write a prescription for Pennsaid. This topical form of diclofenac has been tested in several clinical trials and found to produce long-lasting relief from osteoarthritis. You would then need to contact a Canadian pharmacy online or by phone to have the prescription filled. Since this drug is not available.
**** Pennsaid Lotion (diclotenat)
This topical NSAID has been shown to provide lasting relief from the pain and inflammation of osteoarthritis. It may produce some skin irritation, but does not appear to cause significant systemic toxicity, as oral diclofenac does.
Side effects: Skin dryness, flakiness, and rash
Downside: Not available in the United States. Available by prescription in Canada, Finland, Iceland, Italy, Greece, Portugal, the United Kingdom, and elsewhere.
Cost: Approximately $60 to $120 per month