#40 Topical NSAIDs: Do they top Placebo or Oral NSAIDs?
CLINICAL QUESTION
Are topical non-steroidal anti-inflammatories (NSAIDs) effective in reducing pain in acute and chronic (including osteoarthritis) musculoskeletal pain?
BOTTOM LINE
In acute and chronic (like osteoarthritis) musculoskeletal pain, topical NSAIDs are superior to placebo and equivalent to oral NSAIDs. Topical NSAIDs adverse event rates are not statistically greater than placebo.
Reading Tools for Practice Article can earn you MainPro+ Credits
Join NowAlready a CFPCLearn Member? Log in
EVIDENCE
Acute musculoskeletal pain: Systematic review of 47 randomized controlled trials (RCTs) with 5,512 patients (within 24-48 hours onset).1
- Clinical success (defined as 50% pain reduction, good pain relief, or equivalent): Statistically significantly greater with topical NSAID vs. placebo, relative benefit 1.5 [Confidence Interval (CI) 1.4-1.6].
- Topical NSAID 65% vs. placebo 43%, Number Needed to Treat (NNT)=5.
- Topical diclofenac, ibuprofen, ketoprofen, and piroxicam were all effective.
- Adverse events and withdrawals were not different.
- Benefit decreased over time: 6-8 days NNT=4 and 9-14 days NNT=10.
- This may be due to recovery over time in the placebo arm.
- Short-term (two weeks) effects: Consistent statistically significant improvement.2,3 Example, relative benefit 1.9 (CI 1.7-2.2), NNT=5 for improved pain over placebo.3
- Long-term (=12 weeks) effects: Statistically significant pain reduction vs. placebo, NNT=11.5
- Comparing topical to oral NSAIDs: Pain control is similar (relative risk 1.1, CI 0.9-1.3).3,5 Overall withdrawals for adverse effects is also similar.5
- Other meta-analyses6,7 support topical NSAIDs in acute musculoskeletal pain or single joint osteoarthritis.
- Present evidence does not support topical NSAIDs in back pain, neuropathic conditions or widespread pain.7
- UK osteoarthritis guidelines place topical NSAIDs (or acetaminophen) as first line pharmacotherapy for knee and/or hand osteoarthritis.8
- Intra-articular NSAID levels are therapeutic with topical or oral but circulation levels of topical NSAIDs are 15% of oral NSAIDs.8
- Recommending specific formulations is challenged by the lack of trials comparing different formulations (types of gels/creams) on clinical outcomes.
Latest Tools for Practice
#348 How to Slow the Flow III: Tranexamic acid for heavy menstrual bleeding (Free)
In premenopausal heavy menstrual bleeding due to benign etiology, does tranexamic acid (TXA) improve patient outcomes?
#347 Chlorthali-D’OH!: What is the best thiazide diuretic for hypertension?
Which thiazide diuretic is best at reducing cardiovascular events in hypertension?
#346 Stress Urinary Incontinence: Pelvic floor exercises or pessary? (Free)
How effective are pelvic floor exercises or pessaries for stress urinary incontinence?
