Lateral Epicondylitis Medication
- Author: Bryant James Walrod, MD; Chief Editor: Sherwin SW Ho, MD more...
Medication Summary
Medical intervention is geared toward the joint goals of decreasing inflammation and providing analgesia. The major concern with all the drugs used is their effect on the gastrointestinal (GI) tract with long-term use. Renal function must also be monitored with long-term NSAID use. Long-term corticosteroids have a myriad of side effects, which are beyond the scope of this article.
Nonsteroidal anti-inflammatory drugs
Class Summary
NSAIDs are used to help reduce inflammation and are used as analgesics. Multiple drugs are in this class and every physician should be aware of drugs in each subclass because some patients respond better to one subclass than another. A few of the medications are named not to belabor the wide variety of choices available.
Diclofenac (Cataflam, Voltaren)
Designated chemically as 2-[(2,6-dichlorophenyl) amino] benzeneacetic acid, monosodium salt, with an empirical formula of C14 H10 Cl2 NO2 NA. One of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. Believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins. Can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 weeks of treatment.
Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. The delayed-release, enteric-coated form is diclofenac sodium, and the immediate release form is diclofenac potassium. Has a relatively low risk for bleeding GI ulcers.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Naproxen and naproxen sodium (Aleve, Naprelan, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Available in many dosages and delivery systems. Oral suspension is available at a dose of 125 mg/5 mL. Fairly inexpensive and has a similar therapeutic profile to the other NSAIDs.
Cyclooxygenase 2 (COX-2) inhibitors
Class Summary
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
Celecoxib (Celebrex)
Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus the incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared with nonselective NSAIDs. Seek the lowest dose for each patient.
Neutralizes circulating myelin antibodies through anti-idiotypic antibodies; downregulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).
Has a sulfonamide chain and is primarily dependent upon cytochrome P450 enzymes (a hepatic enzyme) for metabolism.
Corticosteroids
Class Summary
Corticosteroids are some of the strongest anti-inflammatory agents available. The injectable preparations make it possible to deliver the drug directly to the joint in a concentrated dose while greatly decreasing the systemic effects.
Triamcinolone (Amcort, Aristospan Intra-Articular)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Betamethasone (Celestone Soluspan)
Author's drug of choice for intra-articular injections. Preparation does not crystallize if used with paraben-free anesthetic preparations.
Vasodilators
Class Summary
Vasodilators may stimulate collagen synthesis and improve healing. These agents may also effectively treat pain.
Nitroglycerin transdermal (Nitro-Dur)
Causes relaxation of vascular smooth muscle by stimulating intracellular cyclic guanosine monophosphate production.
The dosages available include 0.1mg/h, 0.2mg/h, 0.3mg/h, 0.4mg/h, 0.6mg/h, 0.8mg/h per patch
Neuromuscular Blocker Agent, Toxin
Class Summary
Neuromuscular blocker agents have been shown to decrease pain.
Botulinum Toxin Type A (Botox)
Botulinum neurotoxin is produced by the gram-negative anaerobic bacterium Clostridium botulinum. This agent acts by interrupting signal transmission within the peripheral and sympathetic nervous system, leaving sensory transmission intact. Botulinum toxins block acetylcholine release, causing a chemical denervation.
Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. Nov 4 2006;333(7575):939. [Medline]. [Full Text].
Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clin Rheumatol. Aug 2008;27(8):1015-9. [Medline].
Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis. J Orthop Sports Phys Ther. Jun 2009;39(6):484-9. [Medline].
Lin CL, Lee JS, Su WR, Kuo LC, Tai TW, Jou IM. Clinical and Ultrasonographic Results of Ultrasonographically Guided Percutaneous Radiofrequency Lesioning in the Treatment of Recalcitrant Lateral Epicondylitis. Am J Sports Med. Aug 11 2011;[Medline].
Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg Am. Mar 2003;28(2):272-8. [Medline].
Connell DA, Ali KE, Ahmad M, Lambert S, Corbett S, Curtis M. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol. Jun 2006;35(6):371-7. [Medline].
Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE. Comparison of autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study. J Hand Surg Am. Aug 2011;36(8):1269-72. [Medline].
Kazemi M, Azma K, Tavana B, Rezaiee Moghaddam F, Panahi A. Autologous blood versus corticosteroid local injection in the short-term treatment of lateral elbow tendinopathy: a randomized clinical trial of efficacy. Am J Phys Med Rehabil. Aug 2010;89(8):660-7. [Medline].
Thanasas C, Papadimitriou G, Charalambidis C, Paraskevopoulos I, Papanikolaou A. Platelet-Rich Plasma Versus Autologous Whole Blood for the Treatment of Chronic Lateral Elbow Epicondylitis. Am J Sports Med. Aug 2 2011;[Medline].
Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clin Rheumatol. Mar 26 2008;epub ahead of print. [Medline].
Borkholder CD, Hill VA, Fess EE. The efficacy of splinting for lateral epicondylitis: a systematic review. J Hand Ther. Apr-Jun 2004;17(2):181-99. [Medline].
Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. Jul 2005;39(7):411-22; discussion 411-22. [Medline].
[Best Evidence] Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis. J Orthop Sports Phys Ther. Jun 2009;39(6):484-9. [Medline].
[Best Evidence] Buchbinder R, Green SE, Youd JM, et al. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev. Oct 19 2005;CD003524. [Medline].
Smidt N, Assendelft WJ, Arola H, et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann Med. 2003;35(1):51-62. [Medline].
Ramsay DJ, Bowman MA, Greenman, PE, et al, for the NIH Consensus Panel. NIH Consensus Conference. Acupuncture. JAMA. Nov 4 1998;280(17):1518-24. [Medline].
Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg [Am]. Mar 2003;28(2):272-8. [Medline].
Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. Nov 2006;34(11):1774-8. [Medline].
[Best Evidence] Wong SM, Hui AC, Tong PY, et al. Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. Dec 6 2005;143(11):793-7. [Medline]. [Full Text].
[Best Evidence] Placzek R, Drescher W, Deuretzbacher G, Hempfing A, Meiss AL. Treatment of chronic radial epicondylitis with botulinum toxin A. A double-blind, placebo-controlled, randomized multicenter study. J Bone Joint Surg Am. Feb 2007;89(2):255-60. [Medline].
[Best Evidence] Hayton MJ, Santini AJ, Hughes PJ, et al. Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study. J Bone Joint Surg Am. Mar 2005;87(3):503-7. [Medline].
Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med. Nov-Dec 2003;31(6):915-20. [Medline].
Zeisig E, Fahlström M, Ohberg L, Alfredson H. Pain relief after intratendinous injections in patients with tennis elbow: results of a randomised study. Br J Sports Med. Apr 2008;42(4):267-71. [Medline].
Brosseau L, Casimiro L, Milne S, et al. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev. 2002;CD003528. [Medline].
Baker CL Jr, Baker CL 3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. Feb 2008;36(2):254-60. [Medline].
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