Topical NSAIDs for acute pain in adults

  • Review
  • Intervention

Authors

  • Thomas Massey,

    1. University of Oxford, Pain Research and Nuffield Department of Anaesthetics, Oxford, UK
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  • Sheena Derry,

    Corresponding author
    1. University of Oxford, Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), Oxford, Oxfordshire, UK
    • Sheena Derry, Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), University of Oxford, Pain Research Unit, Churchill Hospital, Oxford, Oxfordshire, OX3 7LE, UK. sheena.derry@ndcn.ox.ac.uk.

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  • R Andrew Moore,

    1. University of Oxford, Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), Oxford, Oxfordshire, UK
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  • Henry J McQuay

    1. University of Oxford, Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), Oxford, Oxfordshire, UK
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Abstract

Background

Use of topical NSAIDs to treat acute musculoskeletal conditions is widely accepted in some parts of the world, but not in others. Their main attraction is their potential to provide pain relief without associated systemic adverse events.

Objectives

To review the evidence from randomised, double-blind, controlled trials on the efficacy and safety of topically applied NSAIDs in acute pain.

Search methods

We searched MEDLINE, EMBASE, The Cochrane Library, and our own in-house database to December 2009. We sought unpublished studies by asking personal contacts and searching on-line clinical trial registers and manufacturers web sites.

Selection criteria

We included randomised, double-blind, active or placebo (inert carrier)-controlled trials in which treatments were administered to adult patients with acute pain resulting from strains, sprains or sports or overuse-type injuries (twisted ankle, for instance). There had to be at least 10 participants in each treatment arm, with application of treatment at least once daily.

Data collection and analysis

Two review authors independently assessed trial quality and validity, and extracted data. Numbers of participants achieving each outcome were used to calculate relative risk and numbers needed to treat (NNT) or harm (NNH) compared to placebo or other active treatment.

Main results

Forty-seven studies were included; most compared topical NSAIDs in the form of a gel, spray, or cream with a similar placebo, with 3455 participants in the overall analysis of efficacy. For all topical NSAIDs combined, compared with placebo, the number needed to treat to benefit (NNT) for clinical success, equivalent to 50% pain relief, was 4.5 (3.9 to 5.3) for treatment periods of 6 to 14 days. Topical diclofenac, ibuprofen, ketoprofen, and piroxicam were of similar efficacy, but indomethacin and benzydamine were not significantly better than placebo. Local skin reactions were generally mild and transient, and did not differ from placebo. There were very few systemic adverse events or withdrawals due to adverse events. There were insufficient data to reliably compare individual topical NSAIDs with each other or the same oral NSAID.

Authors' conclusions

Topical NSAIDs can provide good levels of pain relief, without the systemic adverse events associated with oral NSAIDs, when used to treat acute musculoskeletal conditions.

Plain language summary

Topical non steroidal anti inflammatory drugs (NSAIDS) for acute pain in adults

Topical nonsteroidal anti-inflammatory drugs (NSAIDS) are applied to the skin in the form of a gel, cream, or spray in the region where pain is experienced (a sprained ankle, for instance). They are typically used for strains or sprains, rather than headache or abdominal pain. The attraction of topical application of NSAIDS is that blood concentrations are typically less than 1/20th of those found with oral NSAIDs, minimising the risk of serious harm.

Topical NSAIDs have to penetrate the skin, enter tissues or joints, and be present in a high enough concentration to have an effect on the inflammatory processes causing pain. The evidence from a large number of studies is that topical NSAIDs work well, though evidence for good effect is available only for topical diclofenac, ibuprofen, ketoprofen, and piroxicam. About 6 or 7 out of 10 patients will have successful pain control over seven days with topical NSAID, compared with 4 out of 10 with placebo; the high response with placebo is because conditions like sprained ankles tend to get better on their own eventually. For every four or five participants treated with one of these topical NSAIDs, one would experience good pain relief (equivalent to at least 50% reduction) after about one week, who would not have done if treated with placebo.

Local adverse events at the site of application are no worse with topical NSAID than with topical placebo; they are mild and transient, and occur in about 6% of participants. Systemic adverse events (nausea, stomach upset, for example) and adverse event withdrawals were uncommon, occurring no more frequently with topical NSAID than topical placebo. No serious adverse events were reported in these studies.

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