Joint Pains and Aromatase Inhibitors/Tamoxifen

Aromatase inhibitors (AIs) and tamoxifen are critically important hormonal drugs to help prevent the recurrence of certain types of breast cancers.  Unfortunately, they can have a multitude of side effects.  Joint pains are the side effects that I most frequently encounter. Patients are often referred to me by their oncologists to help manage these symptoms.  This is one of the most rewarding parts of my job, because I know that if I can help the patient tolerate this medication, I may be helping to prevent the cancer from coming back. 

While it is not completely clear why this side effect occurs, the decreased estrogen levels caused by these medications, most likely increases inflammation in the body, leading to pain.  If someone has a pre-existing muscle, tendon, or joint problem, it very commonly will get worse while on these medications.  I frequently see hip, knee, back, hand, and foot pain.  Other very common problems I see are carpal tunnel syndrome, wrist tendinitis, and trigger fingers (stuck fingers).  Often, the symptoms will look just like run of the mill arthritis, but when I take x-rays of the achy joint it is completely normal!  This is often surprising when the joint is so painful but it tells me that while the joint is not wearing down, it is likely just inflamed from the medication.

Unfortunately, as I tell my patients right up front, there is no magic potion to make these symptoms go away.  Every patient is different and so my treatment plans are very much individualized based on the type of pain a patient has, where the pain is located, how many muscles/joints are involved, the patient’s weight and baseline fitness status, what type of exercise the patient likes (or doesn’t like) to do, and overall functional goals.  I like to create both a global and focal approach.  By this, I mean that I like to use a global approach which will hopefully help with symptoms all over the body, in addition to a focal approach to attack a particularly bothersome part of the body.

Below are options that can help with overall body pain:

1) Exercise: This is typically my most difficult conversation during a visit with a patient.  It seems very counterintuitive that starting a cardiovascular exercise program is going to help the patient’s achy joints.  Often times patients will tell me that exercising is the last thing they could imagine doing.  However, there is great scientific evidence that exercise can help with these symptoms.  The key is to get people started slowly.  If a patient is completely foreign to exercise, I will send them to one of my physical therapists to help get them started in a program.  If the patient is fairly comfortable with exercise, I may give them an individually tailored exercise program.  If the person starts slowly and builds up over time, in general they will tolerate the exercise and slowly begin to feel better.  If a particular joint is very bothersome (like a knee or hip), I may help them with a brace, or modify the exercise program to take that into consideration.

      2) Medications: There is no single medication that works well for everyone.  Some of my patients do very well on just over the counter acetaminophen or ibuprofen.  PLEASE keep in mind that even though these are over the counter drugs, they can still have side effects, so please discuss this with your doctor.  Topical medications (like diclofenac gel) can also work wonders for these symptoms, but sometimes insurance doesn’t cover this prescription medication.  If these simple approaches don’t work, I may prescribe medications like Lyrica (pregabalin) or Cymbalta (duloxetine).  While there have been no major studies looking at Lyrica for these symptoms, I have seen it work well for some patients.  There is good evidence that Cymbalta does work for these symptoms.  Unfortunately, some patients don’t tolerate these medications due to side effects.  Keep in mind that just because a side effect is listed by a drug company, it does not mean that YOU will get that side effect.  Many of my patients tolerate these drugs without side effects.

      3) Acupuncture: Many people ask me about acupuncture and my answer is always the same – there is no reason not to try it.  It is a very safe and effective treatment that has been around for a few gazillion years for a reason – it often works!  There is good scientific evidence that shows that acupuncture works for these symptoms.  If you have lymphedema or are at risk for lymphedema, you may want to avoid needles in that at-risk arm.

      4) Glucosamine/chondroitin sulfate: These are very safe supplements that can help to restore normal joint surfaces.  The dose that has been studied is glucosamine 1500 mg/day and chondroitin sulfate 1200 mg/day.  There is reasonably good evidence that this may help these symptoms.  Use caution if you have a shellfish allergy.  I usually tell people that the most common side effect is that it effects your pocketbook.  This will not be insurance covered so you need to pay out of pocket.  Most people notice it helping within 4-6 weeks, so if it’s not helping by that point, it’s probably not worth continuing it.

      5) Vitamin D: At this point, there have been some studies showing low Vitamin D levels may lead to more joint pains while on hormon therapy, and another refuting that.  Therefore, I’m not sure what the best thing is to recommend regarding Vitamin D.  However, what I typically do is draw your blood to check your Vitamin D level.  If it is low, it’s probably a good idea to take a Vitamin D supplement.

Now let’s discuss what I call the focal approach.  If there is a specific part of the body that’s particularly bothersome I will try to use specific strategies for that.  For example, if the biggest problem is wrist tendinitis, I will typically prescribe occupational hand therapy, a wrist splint, a topical anti-inflammatory and possibly perform an injection if all else fails.  If one knee is very painful, I may prescribe physical therapy for the knee, a knee brace, and possibly a knee injection if all else fails. 

I typically find that a combination of global and focal treatments leads to success.  There may be some trial and error involved before coming up with the perfect treatment.  For that reason I like to see patients quite frequently until we have found the right treatment.  With a little bit of effort, we can often find the right approach which will help the patient tolerate these potentially life saving medications.

Lastly, if you are experiencing these symptoms and your oncologist has not helped you tolerate the symptoms, ask to be referred to a specialist – preferably a cancer rehab specialist (physiatrist) like me.   If your oncologist doesn’t know a physiatrist – ask them to find one.  If the oncologist’s office or cancer center doesn’t have a physiatrist – tell them to ask their medical director to look into hiring one.   If you are an oncologist reading this blog post – try to get your cancer center to hire a physiatrist, or at least find one in your area that you can send patients to.   Orthopedists typically are not interested in managing these symptoms (since there is no indication for surgery), so physiatrists are the best equipped physicians to help with this problem.