According to a commentary, the most remarkable finding of this network meta-analysis is that paracetamol does not seem to confer any demonstrable effect or benefit in osteoarthritis, at any dose. It notes however that this finding is not entirely unexpected, as paracetamol has been on the market for a long time and its efficacy has never been properly established or quantified in chronic diseases, and is probably not as great as many would believe. Furthermore, its safety has also been called into question, not just in overdose. The commentators discuss whether recommending it as the universal first-line analgesic in osteoarthritis is still tenable. They speculate that many patients could be suffering needlessly because of perceived NSAIDs risks and paracetamol benefits (which might not be real). They call on researchers to reassess these perceptions (or misconceptions) and the use of other analgesic options that have been discarded over time. They note that opioids are not a good solution for benign pain, and chondroitin sulphate or glucosamine might not be very effective either, but could be safer than paracetamol or opioids. They conclude that there is a crucial need to find new painkillers for osteoarthritis.
NICE guidance on osteoarthritis from 2008 was updated in 2014. This guideline update was originally intended to include recommendations based on a review of new evidence about the use of paracetamol, etoricoxib and fixed-dose combinations of NSAIDs plus gastroprotective agents. Draft recommendations based on the evidence reviews for these areas were presented in the consultation version of the guideline. Stakeholder feedback at consultation indicated that the draft recommendations, particularly in relation to paracetamol, would be of limited clinical application without a full review of evidence on the pharmacological management of osteoarthritis. NICE was also aware of an ongoing review by the MHRA of the safety of over-the-counter analgesics. Therefore it intended to commission a full review of evidence on the pharmacological management of osteoarthritis, to start once the MHRA's review is completed, to inform a further guideline update. Until then, NICE advised that the original recommendations (from 2008) on the pharmacological management of osteoarthritis remain current, i.e. offer paracetamol for pain relief in addition to core treatments; regular dosing may be required. Paracetamol and/or topical NSAIDs should be considered ahead of oral NSAIDs, COX-2 inhibitors or opioids. However, the Guideline Development Group (GDG) did highlight the findings of the evidence review on the effectiveness of paracetamol that was presented in the consultation version of the guideline which identified reduced effectiveness of paracetamol in the management of osteoarthritis compared with what was previously thought. The GDG believes that this information should be taken into account in routine prescribing practice until the planned full review of evidence on the pharmacological management of osteoarthritis is published.
In 2013, the MHRA issued new guidance, contra-indicating the use of diclofenac in patients with established ischaemic heart disease, peripheral arterial disease, cerebrovascular disease, and congestive heart failure (NYHA class II–IV). It advised that patients with these conditions should be switched to an alternative treatment, and diclofenac treatment should only be initiated after careful consideration for patients with significant risk factors for cardiovascular events (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking). Furthermore, the decision to prescribe an NSAID should be based on an assessment of a patient’s individual risk factors, including any history of cardiovascular and gastrointestinal disease. Naproxen and low-dose ibuprofen were considered to have the most favourable thrombotic cardiovascular safety profiles of all non-selective NSAIDs.
“An article from NHS Choices has also covered this meta-analysis as a patient level communication and puts into context certain media reports of this evidence”