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Q Are topical non-steroidal anti-inflammatory drugs (NSAIDs) efficacious for treatment of osteoarthritis?
Medline, CINAHL, EMBASE/Excerpta Medica, Scientific Citation Index, and Cochrane Library (up to October 2003); reference lists; and conference abstracts from international societies of rheumatology (2002–3).
Study selection and assessment:
randomised controlled trials (RCTs) in any language that compared topical NSAIDs with placebo or oral NSAIDs in patients with clinical or radiographic evidence of osteoarthritis. Individual study quality was assessed based on randomisation, blinding, and withdrawals.
reduction in pain (global pain or pain at rest) from baseline, change in function or stiffness, and adverse events (eg, gastrointestinal, central nervous system, and local events).
13 trials (16 comparisons, n = 2224) met the selection criteria. Mean age of patients ranged from 61–67 years. Comparison groups were placebo (13 comparisons, n = 1460) and oral NSAIDs (3 comparisons, n = 764).
Topical NSAIDS v placebo. Topical NSAIDs reduced pain and improved function more than placebo during the first 2 weeks of treatment but not during weeks 3 and 4 (table⇓). Topical NSAIDs improved stiffness more than placebo during the first week but not during weeks 2–4 (table⇓). Topical NSAIDS did not differ from placebo for adverse events.
Topical v oral NSAIDs. Topical NSAIDs were less effective than oral NSAIDs for pain reduction in the first week, but did not differ for weeks 2–4 (table⇑). Topical NSAIDs did not differ from oral NSAIDs for adverse events, gastrointestinal events, or withdrawals because of adverse events; however, more patients who received topical NSAIDs had local events, such as rash, itch, and burning (7.4% v 1%, relative risk increase 429%, 95% CI 14 to 2351).
In patients with osteoarthritis, topical non-steroidal anti-inflammatory drugs (NSAIDs) reduce pain during the first 2 weeks of use but do not differ from placebo at 3 or 4 weeks. Topical NSAIDS are less effective than oral NSAIDs during the first week but do not differ from oral NSAIDs for weeks 2–4.
See commentary on next page.
The systematic reviews by Zhang et al and Lin et al examined the effectiveness of oral and topical treatments for osteoarthritis. These treatments have been recommended by the American College of Rheumatology1 and in treatment guidelines developed in Europe and the UK.2,3 The use of paracetamol and topical NSAIDs must be even more closely examined in light of the withdrawal of rofecoxib from the market.
In a thorough review, Lin et al concluded that topical NSAIDs were superior to placebo in reducing pain and improving function, although effects waned after 2 weeks. The authors also noted that effects differed based on the specific drug. Comparisons of topical and oral NSAIDs were based on only 1 or 2 studies, and comparisons of various topical agents were not done in this review. The well done systematic review by Zhang et al examined the efficacy of paracetamol for reducing osteoarthritis pain and concluded that paracetamol is effective and safe for osteoarthritis pain relief. A similar review published in the Cochrane Library found that oral NSAIDs are more effective, but perhaps less safe, than paracetamol in reducing osteoarthritis pain.4
The results of these 2 reviews are important to nurses who work with geriatric patients, community health nurses, and advanced practice nurses who might prescribe or recommend treatments for patients with osteoarthritis. Historically, paracetamol and topical treatments have been the mainstay of osteoarthritis therapies. Approximately 5 years ago, a new category of drugs (cyclooxygenase-2 [COX 2] inhibitors) came onto the market and virtually revolutionised osteoarthritis care. Clinical trials showed that COX 2 inhibitors safely reduced osteoarthritis pain with short term use.5 Rofecoxib, the first COX 2 inhibitor to be approved, was recently voluntarily withdrawn by the manufacturer because of increased cardiovascular complications with long term use. Although several other COX 2 inhibitors are still available, long term use of these agents for osteoarthritis will no doubt be scrutinised.
Healthcare providers can use the results of these reviews to recommend topical NSAIDs for short term treatment of temporary osteoarthritic flares only, as they do not appear to be useful as chronic therapies. Paracetamol is an effective treatment and should be recommended as a first line treatment. Healthcare researchers should focus future efforts on comparing various topical drugs and comparing topical and oral NSAIDs to determine their relative efficacy, safety, and longevity of action.
For correspondence: Dr W Zhang, University of Nottingham, City Hospital, Nottingham, UK.
Source of funding: UK Arthritis Research Campaign.