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SP0038 Do Nonsteroidals have a Role in the Management of Noninflammatory Pain? Clinical Trials vs Guidelines
  1. D. van der Windt
  1. Arthritis Research UK Primary Care Centre, Keele University, Keele, United Kingdom


A recent review of guidelines for the management of osteoarthritis has highlighted the agreement of recommendations across guideline organisations regarding the pharmacological treatment of osteoarthritis [1]. Acetaminophen (paracetamol) is consistently recommended as the mainstay frontline analgesic for treating non-inflammatory pain (in addition to non-pharmacological interventions such as education, self-management and exercise), with NSAIDs as the second line analgesic. However, this recommendation appears to be based on limited evidence in terms of direct comparisons between NSAIDs and paracetamol, which would be most informative for clinical decision making. A review published in 2004 identified more guidelines (n=9) than trials (n=5) directly comparing NSAIDs to paracetamol in patients with osteoarthritis, highlighting gaps in the quantity and quality of evidence [2]. Based on three trials of adequate methodological quality, this review showed a small difference in pain relief in favour of NSAIDs compared with paracetamol (standardised mean difference -0.33, 95% confidence interval -0.51 to -0.15). Similarly in back pain, a Cochrane review identified only three trials with direct comparisons, demonstrating a small benefit for NSAIDs compared with paracetamol (standardised mean difference -0.21, 95% confidence interval -0.43 to 0.02) [3].

Over the past 10 years numerous guidelines have been published, while the evidence base has also expanded. A more recent meta-analysis identified 15 trials in hip or knee osteoarthritis still showing small benefits of NSAIDs over paracetamol (pooled effect size: -0.29 (95% confidence interval -0.35 to -0.22) [4]. New trials are unlikely to sway the evidence for the effectiveness of NSAIDs for non-inflammatory pain, or change guideline recommendations. However, there still is a lack of data on long-term outcomes, inadequate reporting of safety data, potential publication bias, and relatively few head-to-head comparisons [5]. More advanced approaches to meta-analysis, including trial sequential analysis and network meta-analysis, enable the estimation of comparative effectiveness and ranking of treatment options, providing more useful information to clinicians and patients when making decisions regarding pain relief [e.g. 5]. The lecture will discuss the usefulness of these approaches and how they may inform treatment guidelines or offer guidance regarding the design of future trials.


  1. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Semin Arthritis Rheum 2014;43(6):701-12.

  2. Wegman A, van der Windt D, van Tulder M, Stalman W, de Vries T. Nonsteroidal antiinflammatory drugs or acetaminophen for osteoarthritis of the hip or knee? A systematic review of evidence and guidelines. J Rheumatol 2004 Feb;31(2):344-54.

  3. Roelofs PD, Deyo RA, Koes BW, Scholten RJ, van Tulder MW. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000396.

  4. Verkleij SP, Luijsterburg PA, Bohnen AM, Koes BW, Bierma-Zeinstra SM. NSAIDs vs acetaminophen in knee and hip osteoarthritis: a systematic review regarding heterogeneity influencing the outcomes. Osteoarthritis Cartilage 2011;19(8):921-9.

  5. Bannuru RR, Schmid CH, Kent DM, Vaysbrot EE, Wong JB, McAlindon TE. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Ann Intern Med 2015;162(1):46-54.

Disclosure of Interest None declared

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