Lateral Epicondylitis Medication

Updated: Oct 30, 2018
  • Author: Bryant James Walrod, MD; Chief Editor: Craig C Young, MD  more...
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Medication

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.

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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.

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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.

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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.

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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

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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.

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