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Acute Pain | Chronic Pain | General

Topically applied non-steroidal anti-inflammatory drugs for chronic pain

Clinical bottom line:

Topical NSAIDs provide effective pain relief. This relief seems comparable to that offered by oral NSAIDs. Topical NSAIDs had a combined number-needed-to-treat of 3.1 (2.7 to 3.8) for at least 50% pain relief at two weeks after beginning treatment.

Importantly, topical application of NSAIDs is not associated with serious side effects, and therefore provides an effective method of pain relief without the gastrointestinal effects seen with the same drugs taken orally.


Oral NSAIDs are associated with increased risk of adverse effects such as gastrointestinal problems. The question arises therefore whether topical NSAIDs, which are widely available without prescription, are more suitable for a number of conditions. However, it has also been argued that topical NSAIDs have no action other than as rubefacients.

Systematic review

Moore RA, Carroll D, Wiffen PJ, Tramer M, McQuay HJ A systematic review of topically-applied non-steroidal anti-inflammatory drugs. British Medical Journal 1998; 316:333-8.

Inclusion criteria were randomised controlled trials of NSAIDs with pain outcomes; chronic pain conditions (arthritic and rheumatic); full journal publication and unpublished drug company trials. Trials in vaginitis, oral and buccal conditions, thrombophlebitis and experimental pain were excluded.

Dichotomous data on pain outcomes were extracted from trials for analysis. At least 50% pain relief was regarded as a clinically relevant outcome. From the dichotomous data, information on the proportion, and then the number of patients who achieved at least 50% pain relief were calculated. A number-needed-to-treat for at least 50% pain relief and the relative risk and benefit of the treatment were then calculated. The review also included a meta-analysis of topical NSAID use in acute pain.

Findings

Topical NSAID vs. placebo

Most trials were in single joint arthritis and rheumatological disorders.

Twelve trials reported dichotomous outcomes. Seven of 12 trials showed significant benefit of topical NSAID over placebo. The trial with no dichotomous outcomes also reported significant benefit of topical NSAID over placebo. When the data were combined, the pooled relative benefit was 2.0 (1.5 to 2.7), with a number-needed-to-treat of 3.1 (2.7 to 3.8) for successful treatment.

Figure: At least 50% pain relief with topical NSAID versus placebo

Topical NSAID vs. oral NSAID

Two trials compared topical with oral NSAIDs. Neither showed significant benefit of oral over topical.

Adverse effects

There were no significant differences in the frequency of local or systemic adverse effects or drug-related withdrawals.

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