NSAIDs, Analgesics, and Corticosteroids
Medically reviewed by Anita C. Chandrasekaran, MD, MPH
Rheumatoid arthritis (RA) can affect your life in many ways, but pain seems to have the most effect on people who live with the condition. The primary cause of RA pain is inflammation that leads to joint swelling.
Getting your RA pain under control might take some time and work, and it may require several different medications—some to slow down the disease’s effects and others to alleviate your pain.Keep reading to learn about the medicines that manage RA pain, their side effects, and why your healthcare provider might recommend them.
There are five main classes of drugs used to treat rheumatoid arthritis—disease-modifying antirheumatic drugs (DMARDs), biologics, nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, and corticosteroids. Each drug class will play a different role in managing and treating your RA.
DMARDs: DMARDs, like methotrexate, work by altering the underlying processes of RA, particularly those responsible for inflammation. While they are not painkillers, they can reduce pain, swelling, and stiffness by slowing down RA’s effects.
Biologics: Other types of DMARDs, called biologics, target specific molecules responsible for inflammation. These drugs work much quicker than standard DMARDs.
NSAIDs: NSAIDs work by targeting an enzyme called cyclooxygenase (COX). They prevent COX from making prostaglandins, which are hormones involved in inflammation.
Analgesics: Analgesics can relieve RA pain because they change the way the brain and body sense and respond to pain.
Corticosteroids: Corticosteroid drugs can relieve pain and inflammation quickly by mimicking the effects of cortisol, a hormone naturally found in the body.
Related:The 5 Main Classes of Rheumatoid Arthritis Drugs
DMARDs and biologics are not used for managing pain, stiffness, and swelling associated with RA flare-ups (periods of high disease activity).
Healthcare providers will instead recommend NSAIDs, analgesics, and corticosteroids for this purpose. These drugs are effective at quickly improving joint pain, stiffness, and other RA symptoms. They are considered short-term treatments because of the dangers and risks associated with their long-term use.
Nonsteroidal Anti-Inflammatory Drugs
Most healthcare providers recommend NSAIDs for decreasing RA pain and inflammation. These are sold over the counter (OTC) under different names, including Advil and Aleve. Your healthcare provider can also prescribe stronger versions of OTC pain relievers, as well as ones that are only available with a prescription, such as Celebrex, Cataflam, Indocin, and Mobic.
Ibuprofen is a widely used NSAID that is known for its pain relief and anti-inflammatory benefits. It is available over the counter as a tablet or capsule in doses of 200 to 400 milligrams (mg). Your healthcare provider can prescribe higher doses of 400 mg, 600 mg, or 800 mg to help manage your RA pain.
The two most common OTC name brands of ibuprofen are Advil and Motrin. They can be taken up to three times a day at no more than 1,200 mg per day.
Some ibuprofen tablets are designed to slowly release the medication over a longer period, which can help night-time pain relief. You can buy Advil or other varieties of ibuprofen from your local pharmacy or other retailers.
If OTC ibuprofen doesn’t help you manage your RA pain, or if you need to take something over a longer time, talk to your healthcare provider about prescribing a stronger NSAID or a combination of therapies that could be more effective.
Related:Advil: Benefits and Potential Side Effects
Naproxen is an NSAID used to relieve symptoms of RA and other types of arthritis, including inflammation, swelling, stiffness, and pain. Naproxen comes in two forms: regular naproxen and naproxen sodium, with naproxen sodium being absorbed faster.
Regular naproxen and naproxen sodium come in both oral immediate-release tablets and oral delayed-release tablets. Naproxen is available OTC and in prescription strength to reduce pain and swelling.
OTC naproxen is available under the brand-name Aleve. Prescription name brands of naproxen include Naprosyn, Anaprox, and Naprelan. Naproxen is also available as a generic drug.
Generic drugs are the same medicine as the brand name but will cost less.Generics will have the same "dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use.” This means you can take the generic drug and still get the same benefits and effects as the brand-name drug.
Related:Overview of Aleve (Naproxen)
Celecoxib is a prescription NSAID commonly prescribed to treat joint pain and inflammation. It is available under the brand name Celebrex or as a generic.Celebrex belongs to a class of drugs called COX-2 inhibitors.It comes in capsule form and is available in four different strengths: 50 mg, 100 mg, 200 mg, and 400 mg.
Pain, swelling, and inflammation associated with RA can be greatly reduced using celecoxib. Celebrex dosage for adults with RA is 100 mg to 200 mg twice daily. Celebrex isn’t prescribed for long periods because long-term use is associated with serious side effects. These include heart attack, stroke, and ulcers.
Related:Celebrex (Celecoxib) – Oral
Cataflam (diclofenac) is an NSAID used to treat mild to moderate pain. It is only available as a prescription for treating conditions like RA. It is a short-term treatment and should be taken exactly as your healthcare provider has prescribed. You should follow all instructions carefully for taking Cataflam and let your healthcare provider know if you have questions.
The recommended dose of diclofenac for treating RA is 150 mg to 200 mg per day in divided doses. There are different formulations of diclofenac, including Cataflam, available as immediate-release tablets, and Voltaren-XR, available as extended-release tablets.
An oral solution of diclofenac is also available. It should be taken with food to reduce gastrointestinal discomforts, such as cramping and nausea.
Another form is an OTC diclofenac pain relief cream. It's rubbed on the skin over sore joints for pain relief. It can offer the same relief as oral NSAIDs without the side effects and cardiovascular risks.
Indomethacin is an NSAID used to treat mild to moderate pain, inflammation, joint stiffness, and swelling associated with RA. Indomethacin treats RA and manages pain for as long as you take it. It is only available with a prescription from your healthcare provider. It is available as either a capsule, an extended-release capsule, or an oral suspension.
Before starting indomethacin, you should let your healthcare provider know about all the medications you currently take because it is known for interacting with other medicines. It might be unsafe to use with some medical conditions, so you should let your healthcare provider know about other conditions you may have.
Indomethacin can affect the results of bloodwork. If you are taking this medication, you should let laboratory personnel and your healthcare provider know.
Indomethacin is known for causing severe side effects, including stomach bleeding. It should therefore be used at the lowest effective dose for the shortest amount of time. Make sure you take this medication exactly as your healthcare provider has prescribed.
Meloxicam is an NSAID used to treat symptoms of RA, including inflammation, swelling, stiffness, and pain in the joints. It is available in several forms: tablets, capsules, an oral suspension, and a disintegrating tablet. It is a strong pain reliever and must be prescribed by your healthcare provider. Some popular brands of meloxicam include Mobic, Vivlodex, and Meloxicam Comfort Pac.
Meloxicam works by blocking the enzymes COX-1 and COX-2. Both are known for causing an inflammation-producing substance called prostaglandin.
Under the brand name Mobic, meloxicam is usually given as a single dose of 7.5 mg that can be taken for a maximum of 15 mg per day. The reported side effects of meloxicam are like those of NSAIDs and include stomach troubles and gastrointestinal bleeding.
Related:Mobic (Meloxicam) - Oral
Etodolac is used to relieve pain, stiffness, and swelling from RA. It works by interfering with the production of substances that cause inflammation. It is available as an immediate-release tablet or as an extended-release capsule.
Dosing for etodolac immediate-release tablets starts at 300 mg, two to three times a day, or 400 to 500 mg twice a day.The maximum dose is 1,000 mg per day.
For treating RA, the recommended dosing for etodolac extended-release capsules is 400 mg to 1,000 mg once a day. It is possible to see relief from etodolac as quickly as one to two weeks after starting it.
In the United States, the brand name formulation of etodolac, Lodine, was discontinued. However, the generic form is still available.
Etodolac comes with boxed warnings for cardiovascular and gastrointestinal adverse events.
Boxed warnings, also called “black box warnings” are the strongest warnings the FDA requires. It means that clinical studies have found that a drug carries a significant risk for serious or life-threatening adverse events.
Etodolac may increase the risk for a fatal heart attack or stroke, especially if taken at high doses, for long periods, or in people with underlying heart disease. It should not be used before or after a heart bypass surgery. Etodolac may also increase the risk for stomach or intestinal bleeding, especially in older adults.
Side Effects and Risks of NSAIDs
Like all medications, NSAIDs come with a risk for side effects and other risks.
Side effects are more common if you are taking high doses for long periods, are older, or have serious health conditions. OTC NSAIDs will have fewer side effects compared to stronger prescription NSAIDs.
Possible side effects of NSAIDs include:
Gastrointestinal: Stomach aches, nausea, diarrhea, etc.
Stomach ulcers: Can bleed and lead to anemia
Liver or kidney problems
Heart and circulation problems including heart failure, heart attack, and stroke
The FDA advisory panel has deemed Celebrex as safe as other NSAIDs when it comes to its cardiovascular risks. The panel also recommended changing the labeling to reflect that it still poses a threat to heart health. Research on celecoxib shows it has a lower risk for GI problems, including bleeding and ulcers, compared to other NSAIDs.
If you experience severe side effects from NSAIDs, stop using the medication and let your healthcare provider know.
Some kinds of NSAIDs interact negatively with other medications. This means they can affect how other medicines work and can increase the risk for side effects.
Medications that might interact with an NSAID include:
Medications used to prevent blood clots: Low-dose aspirin and Coumadin (warfarin)
Diuretics: Used to manage blood pressure
Lithium: Used to treat mental health conditions like severe depression and bipolar disorder
Ciclosporin: Used to treat autoimmune diseases
Methotrexate: Used to treat RA
Selective serotonin reuptake inhibitors (SSRIs): Used to treat depression
If you are not sure if a medication you take is safe to take with an NSAID, ask your healthcare provider or pharmacist. There are some foods or drinks you might need to avoid with NSAIDs as well. Read the package labeling or ask your healthcare provider or pharmacist if you are not sure.
Don’t Take Too Much
Taking too much of an NSAID can be dangerous. It can lead to an overdose. Seek out immediate medical attention if you have taken too much of an NSAID medication and you start to feel sick or experience extreme drowsiness or severe abdominal pain.
You should call 911 if you or someone else experience serious signs of an overdose, including seizures, breathing troubles, or loss of consciousness.
Who Shouldn’t Take NSAIDs
According to the Cleveland Clinic, some people shouldn’t take NSAIDs, including:
People who are pregnant, especially in their third trimester of pregnancy
Children and teenagers with viral infections
Someone with an upcoming surgery, including dental surgery
People who consume three or more alcoholic beverages daily
People with asthma that gets worse when taking aspirin
Those who are older than 65
Those with hard to control diabetes
People with kidney or liver disease
Anyone with bleeding problems
People with hard to control blood pressure
Someone with active congestive heart failure
Someone with a history of heart attack or stroke
Relief from pain and swelling; reduces inflammation
Gastrointestinal: abdominal pain or cramps, heartburn, indigestion, nausea, vomiting
Don’t use if you: drink alcohol, use blood thinners, ACE inhibitors, lithium, warfarin, or furosemide; have sensitivity to aspirin; have kidney, liver, or heart disease; have asthma, high blood pressure, ulcers; or take other NSAIDs.
Relieves pain, swelling, stiffness, and pain; offers quick relief
Upset stomach Nausea Heartburn Headache Drowsiness or dizziness
Don’t take if you have: aspirin-sensitive asthma; a blood disorder (such as anemia) or bleeding/clotting problems; heart disease (such as previous heart attack); high blood pressure; liver disease; a history of stroke; fluid retention (edema); stomach/intestinal/esophagus problems (i.e., bleeding, heartburn, ulcers); kidney problems.
Treats pain and inflammation by targeting an enzyme called cyclooxygenase to prevent it from making prostaglandins, which are hormones involved in inflammation
Headache Gastrointestinal problems: abdominal pain, indigestion, bloating, etc. Dizziness Nervousness Runny or stuffy nose
Tell your healthcare provider if you: have a history of high blood pressure, angina, blood clot, heart attack, or stroke; have sensitivity to NSAIDS or sulfa drugs; take other NSAIDs or are pregnant.
Treats mild to moderate RA pain by targeting an enzyme called cyclooxygenase to prevent prostaglandins, hormones involved in inflammation
Gastrointestinal: upset stomach, nausea, heartburn, diarrhea, constipation, gas, etc. Headache Drowsiness Dizziness Elevated blood pressure Increased risk for heart failure with long-term use
Don’t take if you: are allergic to aspirin or have other allergies; have a history of asthma; have a history of bleeding or clotting problems; have heart disease or a history of heart attack; or have high blood pressure, liver or kidney disease, or intestinal/esophagus problems.
Treats mild to moderate pain, inflammation, joint stiffness, and swelling associated with RA; effective for as long as you take it
Upset stomach Heartburn Headache Drowsiness Dizziness Elevated blood pressure
Don't take if you: Are allergic to aspirin or other NSAIDs; have a history of asthma, bleeding or clotting problems, nasal polyps, heart disease, high blood pressure, liver or kidney problems, stomach problems, stroke; or are pregnant, trying to get pregnant, or breastfeeding.
Treats symptoms of RA, including inflammation, swelling, stiffness, and pain in the joints
Gastrointestinal: stomach upset, nausea, bloating, etc.
Don’t take with cyclosporine, lithium, diuretics, methotrexate, blood thinners, corticosteroids, ACE inhibitors, aspirin, or other NSAIDs. Don’t take if you are pregnant or breastfeeding.
Relieves pain, stiffness, and swelling from RA
Gastrointestinal: upset stomach, nausea, diarrhea
Do not use if you are allergic to aspirin or other NSAIDs; have a history of asthma, blood disorders, growths of the nose, heart disease, throat/stomach/intestinal problems, or kidney problems. Do not use with alcohol or if you smoke, if you are about to have surgery, if you are pregnant or plan to become pregnant, or if breastfeeding.
Your healthcare provider might prescribe an analgesic for RA pain relief. Analgesics can relieve pain and inflammation caused by RA, especially during periods of flare-up. Analgesics are considered a short-term solution for pain relief and are often recommended for people who cannot tolerate NSAIDs.
Analgesics like acetaminophen work by blocking pain signals between nerve endings and your brain. Opioids work by attaching themselves to the pain receptors of the brain cells. They can change brain signals and affect the way pain is perceived. Opioids also boost the pleasure sensors in the brain, which makes them highly addictive.
Analgesics can offer quick pain relief, usually within a half-hour of taking them. You should follow all your healthcare provider's advice on taking them, especially with opioids. Analgesics should always be taken as prescribed.
The most commonly used analgesic is acetaminophen under the brand name Tylenol. It is available without a prescription, although your healthcare provider can prescribe a higher strength if they think it might help you manage RA pain.
Acetaminophen is available in many OTC combination medicines, including Midol, Excedrin, Zicam, Vicks, and more. It is also found in many prescription combination drugs, including Ultracet, Vicodin, and Percocet. Acetaminophen can be taken orally, but it can also be given intravenously (through a vein).
The most common side effects of acetaminophen include nausea, vomiting, headache, or insomnia. Serious side effects include excessive sweating and severe tiredness, dark urine, clay color stools, or jaundice. Stop taking acetaminophen if you experience any of these severe side effects, and call your healthcare provider right away.
You should get emergency help if you experience signs of a severe allergic reaction, including hives, breathing difficulties, or swelling of your lips, face, tongue, or throat.In rare cases, acetaminophen can cause a severe skin reaction that might include skin redness, a rash that spreads, blisters, or peeling skin.
The maximum dose of acetaminophen per day is 3 grams (3,000 milligrams). Exceeding this can lead to severe liver damage/failure. Those with underlying liver disease should not take acetaminophen unless it's discussed with their healthcare provider.
Other types of analgesics are considered narcotic analgesics or opioids and are only available with a prescription. Some opioids are combined with acetaminophen for additional pain relief.
Related:Can You Overdose on Tylenol?
Opioids are the strongest pain relief drugs available. Your healthcare provider needs to prescribe them. They are available in pill form to be taken orally or as injections.
Healthcare providers will prescribe opioids to people who have severe RA and experience extreme pain. Opioid medicines include codeine, codeine combined with acetaminophen, fentanyl, Vicodin (hydrocodone), morphine, and Ultram (tramadol).
Opioids are addictive so, if your healthcare provider prescribes them, they will have to closely monitor you.
A 2019 review of cohort studies on opioid use found that up to 40% of people with RA are regular opioid users and the effects of DMARDs do not help reduce the need for opioids. The authors noted that short-term use of an opioid is much more effective for improving RA pain, and long-term use reduces effectiveness and increases safety concerns.
The most common side effects of opioids are drowsiness, confusion, nausea, constipation, breathing troubles, and euphoria (a feeling of well-being or elation). Most drugs have the potential to interact negatively with opioids. Make sure you tell your healthcare provider about all the medications you take, including OTC medicines, so you can reduce the risk of interactions.
Mixing opioid medications with other drugs or alcohol can lead to serious adverse effects, including slowed breathing, a decreased heart rate, and a heightened risk for death. You should call 911 if you experience signs of a medical emergency, including loss of consciousness or going into a deep sleep, very slow breathing, or blue lips or fingernails.
Some people shouldn’t take opioids. This includes children under the age of 12, older children with sleep apnea or lung disease, people with a history of substance misuse, people who are pregnant, and older adults who might forget whether or not they have taken their medications.
When an opioid overdose is suspected,Narcan(naloxone hydrochloride) should be administered as soon as possible. The Food and Drug Administration (FDA) approved Narcan Nasal Spray in March 2023 as an over-the-counter (OTC) emergency treatment for opioid overdose.
Corticosteroids are medicines used to treat RA and other inflammatory conditions. These medications are frequently used because they are effective for reducing inflammation. Examples of corticosteroids include betamethasone, methylprednisolone, dexamethasone, and prednisone.
These medicines are related to cortisol, which naturally occurs in the body. Cortisol is a hormone that is important to many bodily functions, and our bodies need it to survive.
Corticosteroid drugs are not the same as anabolic steroid drugs that are sometimes abused by athletes. Anabolic steroids are synthetic versions of male sex hormones and are often used to treat conditions that cause abnormally low testosterone levels. They are sometimes abused by people who want to improve their physical appearance, such as weightlifters.
Although corticosteroids are quite effective in reducing inflammation, the American College of Rheumatology's updated RA treatment guidelines recommend avoiding these drugs as much as possible due to their potential toxicity.
Celestone (betamethasone injectable)
Injectable betamethasone is used to treat inflammation and pain associated with RA. Betamethasone is also found in topical medicines—creams, gels, lotions, sprays, ointments, and foams. It is available under the brand-name drug Celestone and as a generic.
Injectable betamethasone has to be given by your healthcare provider. You cannot give this type of injection to yourself at home.
Betamethasone can help to reduce the number of inflammatory chemicals the body makes. It can also reduce the body’s overactive immune response, which helps control inflammation.
Some common side effects of betamethasone are headaches, nausea, and sweating. Rare but more serious side effects include wheezing, chest tightness, fever, swelling of the lips, face, tongue, or throat, seizures, and blue lips or blue skin color. Serious side effects might be signs of a medical emergency, and you should call 911.
Corticosteroids can increase your risk for infection. Contact your healthcare provider if you experience infection signs, such as fever, chills, or a cough.
Methylprednisolone is a prescription corticosteroid that can manage symptoms of inflammatory conditions like RA. It is highly effective for treating conditions that affect the immune system.
This medication can improve energy and appetite and work quickly to reduce swelling, skin symptoms, and pain. It is available under the brand name Medrol and as a generic.
Medrol and methylprednisolone can only be prescribed for short periods because of their unwanted side effects, including mood changes, sleep problems, and increased blood pressure or blood sugar. Long-term use can also increase the risk for infections and problems related to skin, bones, and eyes.
People who shouldn’t use Medrol or methylprednisolone include those who:
Are allergic to methylprednisolone, aspirin, tartrazine
Have fungal infections
Have liver, kidney, intestinal, or heart conditions
Are pregnant, planning to become pregnant, or breastfeeding
Are about to have surgery, even dental surgery
Have a history of ulcers
Related:Medrol (Methylprednisolone) - Oral
Rayos is a brand-name drug, with an active ingredient called prednisone in a long-acting/delayed-release formula. Prednisone is a corticosteroid, and it works quickly to reduce inflammation and pain, so healthcare providers will prescribe it in the early stages of RA.
It reduces symptoms while giving DMARDs time to kick in. It is also used for managing RA flares and for people who have not responded to DMARDs and biologics.
Side effects of prednisone depend on the dose and how long you have taken the medicine. Side effects might include:
Gastrointestinal troubles: Stomach pain or diarrhea
Vision changes: Blurred vision or cataracts
Increased blood sugar
Bone changes: Long-term use can lead to weakened bones and eventually, osteoporosis.
Weight gain due to increased appetite
Increased risk for infections
To reduce the potential for side effects, rheumatologists will prescribe the lowest dose possible. When you start prednisone, ask your healthcare provider what to do if you miss a dose. If this issue comes up and you don’t know what to do, call your healthcare provider or pharmacist. Do not take double doses to make up a dose you missed.
If your healthcare provider prescribes prednisone or another corticosteroid for managing RA, they will likely monitor you for side effects and other effects. Your healthcare provider can order bloodwork to see how your body is responding to the medicine.
They can also give you advice on how you can limit side effects, which might include things like avoiding NSAIDs and taking calcium and vitamin D to keep your bones strong.
If your healthcare provider has prescribed prednisone for a longer period at a higher dose, at some point you will need to stop taking it. In this case, your healthcare provider will want to taper you off the medicine slowly.
Do not try to speed up the process because not tapering off can lead to serious adverse effects, including adrenal insufficiency—a condition where the body cannot produce enough cortisol.
RA is one of the common types of autoimmune arthritis. It occurs because the body’s immune system malfunctions and starts attacking healthy tissues, usually the joints. RA can also affect the skin and major organs. But it most commonly attacks your wrists and the small joints of your hands and feet.
Treatments for RA come in many different forms and can help to manage your joint pain and swelling. Treatment can also prevent joint damage and early treatment can improve your quality of life.
You should also include low-impact exercise as part of your treatment plan. This can include activities like walking and swimming, and exercises that improve muscle strength. Exercise will also improve your overall health and reduce the pressure on weight-bearing joints, like the hips and knees.
According to the American College of Rheumatology, people with RA who receive treatment early will feel better sooner and more often, and are likely to lead more active lives. These people are also less likely to experience joint damage that would eventually require joint replacement surgery.
And lastly, make sure you are being treated by a rheumatologist. Rheumatologists are healthcare providers that have additional training in diagnosing and treating arthritis and other conditions that affect the joints, bones, and muscles. A rheumatologist can make sure you have the correct diagnosis and create a treatment plan that can best manage RA.
A Word From Verywell
Rheumatoid arthritis can cause significant pain and disability but treating RA these days is easier and much better than it ever has been. Treatment and pain management are key to improving your outlook and prognosis with RA.
While there is no cure for RA, treatment can slow down the disease’s progress, reduce pain, make symptoms manageable, and prevent joint damage. And continuing advancements in RA treatments mean the outlook for people with the condition is better than it has ever been and will continue to improve.
Most people with RA can live healthy and active lives with mild symptoms for many years or decades with veryfew limitations.