NSAIDs and Acetaminophen Barely Effective for OA, Back Pain

Many orthopaedists and primary care clinicians recommend acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) as a first-line approach for patients with osteoarthritis (OA) or back pain. However, two recent studies call into question how well these pharmacological approaches actually work.

A study employing a new-user design and data from the Osteoarthritis Initiative concluded that short-term use of prescription NSAIDs (such as naproxen, celecoxib, and meloxicam) had no clinical effect in more than 1,800 patients with radiographically confirmed knee osteoarthritis. Long-term use (defined as NSAID use reported at three consecutive annual assessments) was associated with clinically important but not statistically significant improvements in stiffness and function (per WOMAC scales), but not pain. Notably, the rate of NSAID use at all three annual assessments was very low, and the authors concluded that the common discontinuation of NSAID use suggested in this study “call[s] for further understanding of the extent to which potential side effects [of NSAIDs] can be mitigated with gastroprotective agents.”

A meta-analysis of acetaminophen’s effectiveness (13 randomized trials with a total of 5,366 patients) found that the medication did not improve pain, disability, or quality of life for back-pain sufferers, and that its pain-relieving effects in people with knee or hip OA were statistically but not clinically significant. These findings led an editorialist commenting on the meta-analysis to conclude that “the time has come to shift our attention away from tablets as the default option for managing chronic musculoskeletal pain.” As alternatives, he recommended topical NSAIDs, physical therapy, and better coaching on patient self-management. The editorialist also emphasized that these findings should not prompt clinicians to increase prescriptions for opioids.