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Key questions concerning paracetamol and NSAIDs for osteoarthritis
  1. P Courtney,
  2. M Doherty
  1. Academic Rheumatology, Clinical Sciences Building, City Hospital, Nottingham NG5 1PB, UK
  1. Correspondence to:
    Professor M Doherty;

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Paracetamol has a pivotal role in the pharmacological treatment of symptomatic OA

Expert guidelines from both sides of the Atlantic have consistently recommended paracetamol, not non-steroidal anti-inflammatory drugs (NSAIDs), as the initial oral drug treatment for osteoarthritis (OA).1–5 This has been justified by the excellent safety record and low cost of paracetamol relative to NSAIDs, and the absence of any significant clinical benefit of NSAIDs over simple analgesia. However, recent data from the USA suggest that NSAIDs may be better than paracetamol for symptom relief in large joint (hip, knee) OA.6–8 These data follow shortly after an unprecedentedly high profile launch and promotion of selective inhibitors of cyclo-oxygenase 2 (coxibs). The clinical benefit of coxibs in OA is equivalent to that of traditional NSAIDs, but coxibs do not have the increased risk of severe gastrointestinal (GI) side effects (peptic ulceration, bleeding, perforation, and obstruction). In America, particularly, these events have led to an intense debate about the relative role of NSAIDs, coxibs, and paracetamol in OA management. This review deals with key questions relating to such drug prescribing for the management of OA.

Is “which drug to use first” a relevant question?

Although guidelines and reviews about the management of OA seem to be obsessed with this question, it probably has little relevance to clinical practice. Many patients treat themselves before consulting any doctor and have tried over the counter medicines that may include both paracetamol and NSAIDs.8 The concept of which drug to use first implies that monotherapy is the norm. However, most clinical trials of NSAIDs and coxibs allow concomitant paracetamol as “escape analgesia” and in a clinical setting a package of care is usually delivered. As rheumatologists largely see patients with OA only once and after a considerable delay, a more pertinent question for them may be “which drug, or drugs, …

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