Randomized controlled noninferiority trial to compare extended release acetaminophen and ibuprofen for the treatment of ankle sprains

Acetaminophen effects upon formalin-evoked flinching, postformalin, and postincisional allodynia and conditioned place preference

Introduction

We explored in mice, the analgesic, tolerance, dependency, and rewarding effects of systemic acetaminophen (APAP).

Methods

Studies employed adult mice (C57Bl6). (1) Intraplantar formalin flinching + post formalin allodynia. Mice were given intraperitoneal APAP in a DMSO (5%)/Tween 80 (5%) or a water-based formulation before formalin flinching on day 1 and tactile thresholds assessed before and after APAP at day 12. (2) Paw incision. At 24 hours and 8 days after hind paw incision in male mice, effects of intraperitoneal APAP on tactile allodynia were assessed. (3) Repeated delivery. Mice received daily (4 days) analgesic doses of APAP or vehicle and tested upon formalin flinching on day 5. (4) Conditioned place preference. For 3 consecutive days, vehicle was given in the morning in either of 2 chambers and in each afternoon, an analgesic dose of morphine or APAP in the other chamber. On days 5 and 10, animals were allowed to select a "preferred" chamber.

Results

Formalin in male mice resulted in biphasic flinching and an enduring postformalin tactile allodynia. Acetaminophen dose dependently decreased phase 2 flinching, and reversed allodynia was observed postflinching. At a comparable APAP dose, female mice showed similarly reduced phase 2 flinching. Incision allodynia was transiently reversed by APAP. Repeated APAP delivery showed no loss of effect after sequential injections or signs of withdrawal. Morphine, but not APAP or vehicle, resulted in robust place preference.

Conclusions

APAP decreased flinching and allodynia observed following formalin and paw incision and an absence of tolerance, dependence, or rewarding properties.

Analgesic onset and efficacy of a fast-acting formulation of acetaminophen in a postoperative dental impaction pain model

OBJECTIVES

Speed of onset can be critical to an analgesic's efficacy treating acute pain. To enhance onset, a new oral acetaminophen formulation intended to be fast acting was developed. Two studies evaluated the analgesic onset, efficacy, and safety of this fast-acting acetaminophen (FA-acetaminophen) tablet relative to commercial acetaminophen caplets (ES-acetaminophen) and commercial ibuprofen liquid-filled gelatin capsules (LG-ibuprofen).

METHODS

Two single-center, single-dose, inpatient, randomized, double-blind, triple-dummy, placebo-controlled, parallel group design clinical trials were conducted using the postoperative dental impaction pain model. Subjects were healthy men and women aged 17-50 years experiencing moderate-to-severe pain after surgical extraction of at least three impacted third molars. In both studies, four treatment groups were evaluated: 1,000 mg acetaminophen as two 500 mg FA-acetaminophen tablets, 1,000 mg as two 500 mg ES-acetaminophen caplets, 400 mg ibuprofen as two 200 mg LG-ibuprofen capsules, and placebo. To maintain blinding, each subject received six units of study medication. Times to confirmed perceptible pain relief (TCPR) and meaningful pain relief (TMPR) were obtained using the double-stopwatch method. Pain intensity and relief were measured over 6 h following drug administration using a 0-10 numerical rating scale. Time to use of rescue medication (naproxen sodium) and subject global evaluations of study medications at 6 h were collected. Pharmacokinetic blood sampling and safety assessments were performed.

RESULTS

Studies 1 and 2 enrolled 240 and 420 subjects, respectively. No clinically important differences among treatment groups were observed for any demographic or baseline characteristics. Efficacy results showed all active treatments statistically superior to placebo. In Study 1, TCPR was statistically significantly shorter for FA-acetaminophen compared to ES-acetaminophen and LG-ibuprofen. In Study 2, no statistically significant differences in TCPR were noted across the active treatment groups. In Study 1, FA-acetaminophen 1,000 mg provided significantly shorter TMPR compared with LG-ibuprofen but not compared with ES-acetaminophen. In Study 2, no significant differences in TMPR were noted across the active treatment groups. In both Study 1 and 2 at 15 min after administration of study drug, PID and PAR scores were greater for FA-acetaminophen than LG-ibuprofen.

CONCLUSIONS

Both studies suggested FA-acetaminophen had faster onset of action compared to ES-acetaminophen and LG-Ibuprofen. In light of the difference in TCPR and TMPR results between Study 1 and 2, an additional study is needed to further investigate time to analgesic onset of FA-acetaminophen compared with ES-acetaminophen and LG-Ibuprofen.

STUDY REGISTRY NUMBERS

Study 1: NCT02735122; Study 2: NCT03224403.

Current Concept Review: State of Acute Lateral Ankle Injury Classification Systems

Acute lateral ankle sprain (ALAS) is one of the most frequent musculoskeletal injuries, with a great impact on health and socioeconomic factors. There are few consensuses on this subject and multiple therapeutic options that are difficult to compare due to the lack of a universally adopted classification system. The objective of this study is to is to report the actual knowledge on how ALAS are classified and reported and not to make any therapeutic recommendation. A comprehensive literature review of the literature was carried out through a search in the MEDLINE, Cochrane Library and Google Scholar databases, with identification of articles that describe ways to classify lateral ankle sprains or with relevant content for their classification. Twenty-five different classification systems were identified. The majority of articles referring to ALAS use an unspecific classification. Most classification systems divide sprains into 3 degrees. The most used parameters are the anatomy of the injury, clinical parameters, functional loss and the presence of instability. No articles were found to verify the validity of the systems used, namely regarding their association with therapeutic proposals or prognostic predictions. Based on the available evidence, recommendations cannot be made regarding the most appropriate classification system. The considerable heterogeneity of the existing literature makes it difficult to compare studies and to optimize the treatment and follow-up of these injuries. Future research in this area is necessary to define a practical and rigorous system that can be used universally.

Comparison of celecoxib and acetaminophen for pain relief in pediatric day case tonsillectomy: A randomized double-blind study

OBJECTIVE

Post-tonsillectomy pain is a common morbidity in children. The aim of this study was to compare the efficacy of celecoxib with acetaminophen on pain relief in pediatric day-case tonsillectomy.

METHODS

We compared the analgesic effect of celecoxib (99 patients) with acetaminophen (100 patients) for the management of post-tonsillectomy pain. Post-tonsillectomy pain score was evaluated three times a day for 7 days. In addition, the incidence of post-tonsillectomy bleeding and the rate of patients who returned to regular diet were evaluated.

RESULTS

In the first day, we observed lower mean pain score in the celecoxib group, than the acetaminophen group (P =  0.013). The overall pain score in other days was not significantly different between the two groups. In the celecoxib group, more patients resumed regular amount of oral intake within the first 3 days. Also, the rate of post-tonsillectomy bleeding in the two groups was not statistically different.

CONCLUSION

We recommend celecoxib as a more suitable choice than acetaminophen for post-tonsillectomy pain management in the first day and resuming regular diet within 3 days.Level of Evidence: 1b.

Pharmacological Treatment for Acute Traumatic Musculoskeletal Pain in Athletes

Pain management is a crucial issue for athletes who train and compete at the highest performance levels. There are still evidence gaps for the use of analgesics for sports injuries despite the growing interest in training and competition settings. However, high-quality research is needed to determine the most appropriate and optimal timing and formulations in non-steroidal anti-inflammatory drug and opioid management, particularly given the strictness of anti-doping regulations. Indeed, the role of pharmacological therapy in reducing acute traumatic pain in athletes should still be addressed to minimize the timing of return to sport. Therefore, the aim of this comprehensive review was to summarize the current evidence about pain management in the setting of acute injury in elite athletes, providing the most informed strategy for pain relief and performance recovery.

Acute ankle sprain in athletes: Clinical aspects and algorithmic approach

Acute ankle sprain is the most common lower limb injury in athletes and accounts for 16%-40% of all sports-related injuries. It is especially common in basketball, American football, and soccer. The majority of sprains affect the lateral ligaments, particularly the anterior talofibular ligament. Despite its high prevalence, a high proportion of patients experience persistent residual symptoms and injury recurrence. A detailed history and proper physical examination are diagnostic cornerstones. Imaging is not indicated for the majority of ankle sprain cases and should be requested according to the Ottawa ankle rules. Several interventions have been recommended in the management of acute ankle sprains including rest, ice, compression, and elevation, analgesic and anti-inflammatory medications, bracing and immobilization, early weight-bearing and walking aids, foot orthoses, manual therapy, exercise therapy, electrophysical modalities and surgery (only in selected refractory cases). Among these interventions, exercise and bracing have been recommended with a higher level of evidence and should be incorporated in the rehabilitation process. An exercise program should be comprehensive and progressive including the range of motion, stretching, strengthening, neuromuscular, proprioceptive, and sport-specific exercises. Decision-making regarding return to the sport in athletes may be challenging and a sports physician should determine this based on the self-reported variables, manual tests for stability, and functional performance testing. There are some common myths and mistakes in the management of ankle sprains, which all clinicians should be aware of and avoid. These include excessive imaging, unwarranted non-weight-bearing, unjustified immobilization, delay in functional movements, and inadequate rehabilitation. The application of an evidence-based algorithmic approach considering the individual characteristics is helpful and should be recommended.

Application of the DILIsym® Quantitative Systems Toxicology drug-induced liver injury model to evaluate the carcinogenic hazard potential of acetaminophen

In 2019, the California Office of Environmental Health Hazard Assessment (OEHHA) initiated a review of the carcinogenic hazard potential of acetaminophen. The objective of the analysis herein was to inform this review by assessing whether variability in patient baseline characteristics (e.g. baseline glutathione (GSH) levels, pharmacokinetics, and capacity of hepatic antioxidants) leads to potential differences in carcinogenic hazard potential at different dosing schemes: maximum labeled doses of 4 g/day, repeated doses above the maximum labeled dose (>4-12 g/day), and acute overdoses of acetaminophen (>15 g). This was achieved by performing simulations of acetaminophen exposure in thousands of diverse virtual patients scenarios using the DILIsym® Quantitative Systems Toxicology (QST) model. Simulations included assessments of the dose and exposure response for toxicity and mode of cell death based on evaluations of the kinetics of changes of: GSH, N-acetyl-p-benzoquinone-imine (NAPQI), protein adducts, mitochondrial dysfunction, and hepatic cell death. Results support that, at therapeutic doses, cellular GSH binds to NAPQI providing sufficient buffering capacity to limit protein adduct formation and subsequent oxidative stress. Simulations evaluating repeated high-level supratherapeutic exposures or acute overdoses indicate that cell death precedes DNA damage that could result in carcinogenicity and thus acetaminophen does not present a carcinogenicity hazard to humans at any dose.

A critical review of the acetaminophen preclinical carcinogenicity and tumor promotion data and their implications for its carcinogenic hazard potential

In 2019 the California Office of Environmental Health Hazard Assessment (OEHHA) initiated a review of the carcinogenic hazard potential of acetaminophen, including an assessment of the long-term rodent carcinogenicity and tumor initiation/promotion studies. The objective of the analysis herein was to inform this review process with a weight-of-evidence assessment of these studies and an assessment of the relevance of these models to humans. In most of the 14 studies, there were no increases in the incidences of tumors in any organ system. In the few studies in which an increase in tumor incidence was observed, there were factors such as absence of a dose response and a rodent-specific tumor supporting that these findings are not relevant to human hazard identification. In addition, we performed qualitative analysis and quantitative simulations of the exposures to acetaminophen and its metabolites and its toxicity profile; the data support that the rodent models are toxicologically relevant to humans. The preclinical carcinogenicity results are consistent with the broader weight of evidence assessment and evaluations of multiple international health authorities supporting that acetaminophen is not a carcinogenic hazard.

Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury

BACKGROUND

Acute soft tissue injuries are common and costly. The best drug treatment for such injuries is not certain, although non-steroidal anti-inflammatory drugs (NSAIDs) are often recommended. There is concern about the use of oral opioids for acute pain leading to dependence. This is an update of a Cochrane Review published in 2015.

OBJECTIVES

To assess the benefits or harms of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries.

SEARCH METHODS

We searched the CENTRAL, 2020 Issue 1, MEDLINE (from 1946), and Embase (from 1980) to January 2020; other databases were searched to February 2019.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials involving people with acute soft tissue injury (sprain, strain, or contusion of a joint, ligament, tendon, or muscle occurring within 48 hours of inclusion in the study), and comparing oral NSAIDs versus paracetamol (acetaminophen), opioid, paracetamol plus opioid, or complementary and alternative medicine. The outcomes were pain, swelling, function, adverse effects, and early re-injury.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility, extracted data, and assessed risk of bias. We assessed the quality of the evidence using GRADE methodology.

MAIN RESULTS

We included 20 studies, with 3305 participants. Three studies included children only. The others included predominantly young adults; approximately 60% were male. Seven studies recruited people with ankle sprains only. Most studies were at low or unclear risk of bias; however, two were at high risk of selection bias, three were at high risk of bias from lack of blinding, and five were at high risk of selective outcome reporting bias. Some evidence relating to pain relief was high certainty. Other evidence was either moderate, low or very low certainty, reflecting study limitations, indirectness, imprecision, or combinations of these. Thus, we are certain or moderately certain about some of the estimates, and uncertain or very uncertain of others. Eleven studies, involving 1853 participants compared NSAIDs with paracetamol. There were no differences between the two groups in pain at one to two hours (1178 participants, 6 studies; high-certainty evidence), at days one to three (1232 participants, 6 studies; high-certainty evidence), and at day seven or later (467 participants, 4 studies; low-certainty evidence). There was little difference between the groups in numbers of participants with minimal swelling at day seven or later (77 participants, 1 study; low-certainty evidence). Very low-certainty evidence from three studies (386 participants) means we are uncertain of the finding of little difference between the two groups in return to function at day seven or later. There was low-certainty evidence from 10 studies (1504 participants) that NSAIDs may slightly increase the risk of gastrointestinal adverse events compared with paracetamol. There was low-certainty evidence from nine studies (1679 participants) of little difference in neurological adverse events between the NSAID and paracetamol groups. Six studies, involving 1212 participants compared NSAIDs with opioids. There was moderate-certainty evidence of no difference between the groups in pain at one hour (1058 participants, 4 studies), and low-certainty evidence for no difference in pain at days four or seven (706 participants, 1 study). There was very low-certainty evidence of no important difference between the groups in swelling (84 participants, 1 study). Participants in the NSAIDs group were more likely to return to function in 7 to 10 days (542 participants, 2 studies; low-certainty evidence). There was moderate-certainty evidence (1143 participants, 5 studies) that NSAIDs were less likely to result in gastrointestinal or neurological adverse events compared with opioids. Four studies, involving 240 participants, compared NSAIDs with the combination of paracetamol and an opioid. The applicability of findings from these studies is in question because the dextropropoxyphene combination analgesic agents used are no longer in general use. Very low-certainty evidence means we are uncertain of the findings of no differences between the two interventions in the numbers with little or no pain at day one (51 participants, 1 study), day three (149 participants, 2 studies), or day seven (138 participants, 2 studies); swelling (230 participants, 3 studies); return to function at day seven (89 participants, 1 study); and the risk of gastrointestinal or neurological adverse events (141 participants, 3 studies). No studies reported re-injury rates. No studies compared NSAIDs with oral complementary and alternative medicines, AUTHORS' CONCLUSIONS: Compared with paracetamol, NSAIDs make no difference to pain at one to two hours and at two to three days, and may make no difference at day seven or beyond. NSAIDs may result in a small increase in gastrointestinal adverse events and may make no difference in neurological adverse events compared with paracetamol. Compared with opioids, NSAIDs probably make no difference to pain at one hour, and may make no difference at days four or seven. NSAIDs probably result in fewer gastrointestinal and neurological adverse effects compared with opioids. The very low-certainly evidence for all outcomes for the NSAIDs versus paracetamol with opioid combination analgesics means we are uncertain of the findings of no differences in pain or adverse effects. The current evidence should not be extrapolated to adults older than 65 years, as this group was not well represented in the studies.

Paracetamol versus other analgesia in adult patients with minor musculoskeletal injuries: a systematic review

Objectives

Pain treatment in acute musculoskeletal injuries usually consists of paracetamol, non-steroidal antiinflammatory drugs (NSAIDs) or opioids. It would be beneficial to determine whether paracetamol is as effective as other analgesics. The objective of this study was to evaluate available evidence regarding efficacy of paracetamol in these patients.

Methods

Embase, MEDLINE, Cochrane and relevant trial registers were searched from inception to 14 February 2018 by two independent reviewers to detect all randomised studies with adult patients with acute minor musculoskeletal injuries treated with paracetamol as compared with other analgesics. There were no language or date restrictions. Two independent reviewers evaluated risk of bias and quality of evidence. Primary outcome was decrease in pain scores during the first 24 hours, and secondary outcomes included pain decrease beyond 24 hours, need for additional analgesia and occurrence of adverse events.

Results

Seven trials were included, evaluating 2100 patients who were treated with paracetamol or NSAIDs or the combination of both as comparisons, of which only four studies addressed the primary outcome. No studies were found comparing paracetamol with opioids. There were no differences in analgesic effectiveness within and beyond 24 hours, nor in need for additional analgesia and occurrence of adverse events. Overall, quality of evidence was low. Because of methodological inconsistencies, a meta-analysis was not possible.

Conclusions

Based on available evidence, paracetamol is as effective as NSAIDs or the combination of both in treating pain in adult patients with minor musculoskeletal injuries in the acute setting. The quality of evidence is low.

Efficacy of acetaminophen versus ibuprofen for the management of rotator cuff-related shoulder pain: Randomized open-label study

Background

Shoulder pain related to the rotator cuff (RC) is one of the most common and bothersome musculoskeletal complaints. Pharmacologic treatment most often includes acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. However, data allowing comparison of the efficacy of these two drugs are very limited. We compared the therapeutic outcomes of acetaminophen and ibuprofen in the management of RC-related pain.

Methods

This was an open-label, two-center, active-control, prospective randomized clinical trial. Participants were assigned randomly to acetaminophen or ibuprofen treatment groups. The acetaminophen dose was 500 mg every 6–8 h, and it was 400–800 mg every 6–8 h for ibuprofen. The impact of the treatment was measured by Shoulder Pain and Disability Index (SPADI), Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) and World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaires at baseline and after 6 weeks of therapy.

Results

Thirty-three patients completed the study; 20 treated with ibuprofen and 13 with acetaminophen. Patients in both groups were comparable at baseline with regard to SPADI, Quick-DASH, and WHOQOL-BREF scores. After 6 weeks of treatment, patients receiving ibuprofen, but not acetaminophen, reported an improvement in pain severity and functional activity (as measured by SPADI and Quick-DASH). Patients taking acetaminophen, but not ibuprofen, reported improvement in the physical and environmental domains of WHOQOL-BREF scores.

Conclusions

Ibuprofen and acetaminophen provide benefits to patients suffering from RC-related pain. However, the type of improvement perceived by patients differed between these two medications.

Surgical management of chronic lateral ankle instability: a meta-analysis

Background

A key point to surgical treatment of chronic lateral ankle instability is choosing a suitable surgical procedure. The purpose of this meta-analysis was to compare different surgical techniques for management of chronic lateral ankle instability.

Methods

We searched the Cochrane Library, MEDLINE, and EMBASE. All identified randomized and quasi-randomized controlled trials of operative treatment for chronic lateral ankle instability were included. Two review authors independently extracted data from each study and assessed risk of bias. Where appropriate, results of comparable studies were pooled.

Results

Seven randomized controlled trials were included for analysis. They fell in five clearly distinct groups.

One study comparing two different kinds of non-anatomic reconstruction procedures (dynamic and static tenodesis) found two clinical outcomes favoring static tenodesis: better clinical satisfaction and fewer subsequent sprains.

Two studies compared non-anatomic reconstruction versus anatomic repairment. In one study, nerve damage was more frequent in non-anatomic reconstruction group; the other one reported that radiological measurement of ankle laxity showed that non-anatomic reconstruction provided higher reduction of talar tilt angle.

Two studies comparing two anatomic repairment surgical techniques (transosseous suture versus imbrication) showed no significant difference in any clinical outcome at the follow-up except operation time.

One study compared two different anatomic repairment techniques. They found that the double anchor technique was superior with respect to the reduction of talar tilt than single anchor technique.

One study compared an anatomic reconstruction procedure with a modified Brostrom technique. Primary reconstruction combined with ligament advanced reinforcement system results in better patient-scored clinical outcome, at 2 years post-surgery, than the modified Brostrom procedure.

Conclusions

There is limited evidence to support any one surgical technique over another surgical technique for chronic lateral ankle instability, but based on the evidence, we could still get some conclusions: (1) There are limitations to the use of dynamic tenodesis, which obtained poor clinical satisfaction and more subsequent sprains. (2) Non-anatomic reconstruction abnormally increased inversion stiffness at the subtalar level as compare with anatomic repairment. (3) Multiple types of modified Brostrom procedures could acquire good clinical results. (4) Anatomic reconstruction is a better procedure for some specific patients.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0870-6) contains supplementary material, which is available to authorized users.

Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline

This guideline aimed to advance current understandings regarding the diagnosis, prevention and therapeutic interventions for ankle sprains by updating the existing guideline and incorporate new research. A secondary objective was to provide an update related to the cost-effectiveness of diagnostic procedures, therapeutic interventions and prevention strategies. It was posited that subsequent interaction of clinicians with this guideline could help reduce health impairments and patient burden associated with this prevalent musculoskeletal injury. The previous guideline provided evidence that the severity of ligament damage can be assessed most reliably by delayed physical examination (4-5 days post trauma). After correct diagnosis, it can be stated that even though a short time of immobilisation may be helpful in relieving pain and swelling, the patient with an acute lateral ankle ligament rupture benefits most from use of tape or a brace in combination with an exercise programme.New in this update: Participation in certain sports is associated with a heightened risk of sustaining a lateral ankle sprain. Care should be taken with non-steroidal anti-inflammatory drugs (NSAIDs) usage after an ankle sprain. They may be used to reduce pain and swelling, but usage is not without complications and NSAIDs may suppress the natural healing process. Concerning treatment, supervised exercise-based programmes preferred over passive modalities as it stimulates the recovery of functional joint stability. Surgery should be reserved for cases that do not respond to thorough and comprehensive exercise-based treatment. For the prevention of recurrent lateral ankle sprains, ankle braces should be considered as an efficacious option.

Review article: Best practice management of common ankle and foot injuries in the emergency department (part 2 of the musculoskeletal injuries rapid review series)

Ankle and foot injuries are the most common musculoskeletal injuries presenting to Australian EDs and are associated with a large societal and economic impact. The quality of ED care provided to patients with ankle and foot fractures or soft tissue injuries is critical to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common ankle and foot injuries in the ED. Databases including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English language articles published in the last 12 years that addressed the acute assessment, management or prognosis in the ED were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 1242 articles, of which 71 were included in the review (n = 22 primary articles, n = 35 systematic reviews and n = 14 guidelines). This rapid review provides clinicians managing fractures and soft tissue injuries of the ankle and foot in the ED a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. Following a thorough history and physical examination, including the application of the Ottawa ankle rules, ED clinicians should not only provide a diagnosis, but rate the severity of soft tissue injuries, or stability of fractures and dislocations, which are the pivotal decision points in guiding ED treatment, specialist referral and the follow-up plan.

Acetaminophen or Nonsteroidal Anti-Inflammatory Drugs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, Randomized, Clinical Trial

STUDY OBJECTIVE

We determine whether pain treatment with acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the combination of both in minor musculoskeletal trauma.

METHODS

The Paracetamol or NSAIDs in Acute Musculoskeletal Trauma Study was a double-blind, randomized, clinical trial conducted in 2 general practices and 2 emergency departments in the Netherlands. A total of 547 adults, aged 18 years and older, with acute blunt minor musculoskeletal extremity trauma were randomly assigned in a 1:1:1 ratio to acetaminophen 4,000 mg/day, diclofenac 150 mg/day, or acetaminophen 4,000 mg/day+diclofenac 150 mg/day during 3 consecutive days. Patients, health care staff, and outcome assessors were blinded for treatment allocation. Follow-up for each patient was 30 days. Primary outcome measures were between-group differences in mean numeric rating scale (NRS) pain scores in rest and with movement at 90 minutes after initial drug administration compared with baseline pain scores with a predefined noninferiority margin of 0.75 NRS points. Secondary outcomes included NRS pain scores during 3 consecutive days and need for additional analgesia.

RESULTS

One hundred eighty-two patients were treated with acetaminophen, 183 with diclofenac, and 182 with combination treatment. Intention-to-treat analysis revealed mean NRS reduction in rest -1.23 (95% confidence interval [CI] -1.50 to -0.95) and -1.72 (95% CI -2.01 to -1.44) with movement, both for acetaminophen at 90 minutes compared with baseline. Pairwise comparison in rest with diclofenac showed a difference of -0.027 (97.5% CI -0.45 to 0.39) and -0.052 (97.5% CI -0.46 to 0.36) for combination treatment. With movement, these numbers were -0.20 (97.5% CI -0.64 to 0.23) and -0.39 (97.5% CI -0.80 to 0.018), respectively. All differences were well below the predefined noninferiority margin.

CONCLUSION

Pain treatment with acetaminophen was not inferior to that with diclofenac or the combination of acetaminophen and diclofenac in acute minor musculoskeletal extremity trauma, both in rest and with movement.

Pain relief that matters to patients: systematic review of empirical studies assessing the minimum clinically important difference in acute pain

BACKGROUND

The minimum clinically important difference (MCID) is used to interpret the clinical relevance of results reported by trials and meta-analyses as well as to plan sample sizes in new studies. However, there is a lack of consensus about the size of MCID in acute pain, which is a core symptom affecting patients across many clinical conditions.

METHODS

We identified and systematically reviewed empirical studies of MCID in acute pain. We searched PubMed, EMBASE and Cochrane Library, and included prospective studies determining MCID using a patient-reported anchor and a one-dimensional pain scale (e.g. 100 mm visual analogue scale). We summarised results and explored reasons for heterogeneity applying meta-regression, subgroup analyses and individual patient data meta-analyses.

RESULTS

We included 37 studies (8479 patients). Thirty-five studies used a mean change approach, i.e. MCID was assessed as the mean difference in pain score among patients who reported a minimum degree of improvement, while seven studies used a threshold approach, i.e. MCID was assessed as the threshold in pain reduction associated with the best accuracy (sensitivity and specificity) for identifying improved patients. Meta-analyses found considerable heterogeneity between studies (absolute MCID: I² = 93%, relative MCID: I² = 75%) and results were therefore presented qualitatively, while analyses focused on exploring reasons for heterogeneity. The reported absolute MCID values ranged widely from 8 to 40 mm (standardised to a 100 mm scale) and the relative MCID values from 13% to 85%. From analyses of individual patient data (seven studies, 918 patients), we found baseline pain strongly associated with absolute, but not relative, MCID as patients with higher baseline pain needed larger pain reduction to perceive relief. Subgroup analyses showed that the definition of improved patients (one or several categories improvement or meaningful change) and the design of studies (single or multiple measurements) also influenced MCID values.

CONCLUSIONS

The MCID in acute pain varied greatly between studies and was influenced by baseline pain, definitions of improved patients and study design. MCID is context-specific and potentially misguiding if determined, applied or interpreted inappropriately. Explicit and conscientious reflections on the choice of a reference value are required when using MCID to classify research results as clinically important or trivial.

Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury

BACKGROUND

Acute soft tissue injuries are common and costly. The best drug treatment for such injuries is not certain, although non-steroidal anti-inflammatory drugs (NSAIDs) are often recommended.

OBJECTIVES

To assess the effects (benefits and harms) of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014 Issue 8), MEDLINE (1966 to September 2014), EMBASE (1980 to September 2014), CINAHL (1937 to November 2012), AMED (1985 to November 2012), International Pharmaceutical Abstracts (1970 to November 2012), PEDro (1929 to November 2012), and SPORTDiscus (1985 to November 2012), plus internet search engines, trial registries and other databases. We also searched reference lists of relevant articles and contacted authors of retrieved studies and pharmaceutical companies to obtain relevant unpublished data.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials involving people with acute soft tissue injury (sprain, strain or contusion of a joint, ligament, tendon or muscle occurring up to 48 hours prior to inclusion in the study) and comparing oral NSAID versus paracetamol (acetaminophen), opioid, paracetamol plus opioid, or complementary and alternative medicine. The outcomes were pain, swelling, function, adverse effects and early re-injury.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies for eligibility, extracted data and assessed risk of bias. We assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

MAIN RESULTS

We included 16 trials, with a total of 2144 participants. Two studies included children only. The other 14 studies included predominantly young adults, of whom over 60% were male. Seven studies recruited people with ankle sprains only. Most studies were at low or unclear risk of bias; however, two were at high risk of selection bias, three were at high risk of bias from lack of blinding, one was at high risk of bias due to incomplete outcome data, and four were at high risk of selective outcome reporting bias. The evidence was usually either low quality or very low quality, reflecting study limitations, indirectness such from as suboptimal dosing of single comparators, imprecision, or one or more of these. Thus we are either uncertain or very uncertain of the estimates.Nine studies, involving 991 participants, compared NSAIDs with paracetamol. While tending to favour paracetamol, there was a lack of clinically important differences between the two groups in pain at less than 24 hours (377 participants, 4 studies; moderate-quality evidence), at days 1 to 3 (431 participants, 4 studies; low quality), and at day 7 or over (467 participants, 4 studies; low quality). A similar lack of difference between the two groups applied to swelling at day 3 (86 participants, 1 study; very low quality) and at day 7 or over (77 participants, 1 study; low quality). There was little difference between the two groups in return to function at day 7 or over (316 participants, 3 studies; very low quality): based on an assumed recovery of function of 804 per 1000 participants in the paracetamol group, 8 fewer per 1000 recovered in the NSAID group (95% confidence interval (CI) 80 fewer to 73 more). There was low-quality evidence of a lower risk of gastrointestinal adverse events in the paracetamol group: based on an assumed risk of gastrointestinal adverse events of 16 per 1000 participants in the paracetamol group, 13 more participants per 1000 had a gastrointestinal adverse event in the NSAID group (95% CI 0 to 35 more).Four studies, involving 958 participants, compared NSAIDs with opioids. Since a study of a selective COX-2 inhibitor NSAID (valdecoxib) that was subsequently withdrawn from the market dominates the evidence for this comparison (706 participants included in the analyses for pain, function and gastrointestinal adverse events), the applicability of these results is in doubt and we give only a brief summary. There was low quality evidence for a lack of clinically important differences between the two groups regarding pain at less than 24 hours, at days 4 to 6, and at day 7. Evidence from single studies showed a similar lack of difference between the two groups for swelling at day 3 (68 participants) and day 10 (84 participants). Return to function at day 7 or over favoured the NSAID group (low-quality), and there were fewer gastrointestinal adverse events in the selective COX-2 inhibitor NSAID group (very low quality).Four studies, involving 240 participants, compared NSAIDs with the combination of paracetamol and an opioid. The applicability of findings from these studies is partly in question because the dextropropoxyphene combination analgesic agents used are no longer in general use. While the point estimates favoured NSAID, the very low-quality evidence did not show a difference between the two interventions in the numbers with little or no pain at day 1 (51 participants, 1 study), day 3 (149 participants, 2 studies), or day 7 (138 participants, 2 studies). Very low-quality evidence showed a similar lack of difference between the two groups applied to swelling at day 3 (reported in two studies) and at day 7 (reported in two studies), in return to function at day 7 (89 participants, 1 study), and in gastrointestinal adverse events (141 participants, 3 studies).No studies compared NSAIDs with complementary and alternative medicines, and no study reported re-injury rates.

AUTHORS' CONCLUSIONS

There is generally low- or very low-quality but consistent evidence of no clinically important difference in analgesic efficacy between NSAIDs and other oral analgesics. There is low-quality evidence of more gastrointestinal adverse effects with non-selective NSAID compared with paracetamol. There is low- or very low-quality evidence of better function and fewer adverse events with NSAIDs compared with opioid-containing analgesics; however, one study dominated this evidence using a now unavailable COX-2 selective NSAID and is of uncertain applicability. Further research is required to determine whether there is any difference in return to function or adverse effects between both non-selective and COX-2 selective NSAIDs versus paracetamol.

A randomized, double-blind, placebo-controlled multicentre study to evaluate the efficacy and safety of diclofenac 4% spray gel in the treatment of acute uncomplicated ankle sprain

OBJECTIVE

A prospective, randomized, double-blind, placebo-controlled, parallel-group multicentre study to evaluate the efficacy and safety of diclofenac 4% spray gel for the treatment of acute, uncomplicated ankle sprain.

METHODS

Outpatients with acute, uncomplicated, one-sided ankle sprain were randomly assigned to receive diclofenac 4% spray gel or placebo (vehicle) three times daily for 14 ± 1 days. The main efficacy endpoint was the intra-individual response to treatment (≥ 50% decrease in swelling of the injured ankle after a treatment period of ≤ 10 days).

RESULTS

The response rate was significantly higher in the diclofenac group (n = 118) than the placebo group (n = 114) (91.5% vs. 82.5%). After 3-4 days' treatment, diclofenac spray significantly reduced swelling, spontaneous pain, pain on active movement and tenderness compared with placebo. Diclofenac spray was well tolerated, with a low overall rate of adverse events.

CONCLUSIONS

Diclofenac 4% spray gel rapidly relieves pain and improves mobility in patients with acute, uncomplicated ankle sprain and is well tolerated. It may be a useful treatment option for other acute soft tissue injuries.

The PanAM study: a multi-center, double-blinded, randomized, non-inferiority study of paracetamol versus non-steroidal anti-inflammatory drugs in treating acute musculoskeletal trauma

BACKGROUND

Acute musculoskeletal trauma, including strains, sprains or contusions, occur frequently. Pain management is a crucial component of treatment. However, there is no convincing evidence which drug is superior in managing pain in these patients. The aim of the PanAM Study is to compare analgesic efficacy of three strategies of pain management: paracetamol, diclofenac, or a combination of both in patients with acute musculoskeletal trauma.

METHODS/DESIGN

The PanAM Study is a multi-center, double blind randomized controlled trial with non-inferiority design. Included are adult patients presenting to an academic, urban Emergency Department or to a General Practice with acute, blunt, traumatic limb injury. In total, 547 patients will be included using a predefined list of exclusion criteria, to be allocated by randomization to treatment with paracetamol + placebo diclofenac, diclofenac + placebo paracetamol or paracetamol + diclofenac. The hypothesis is that paracetamol will not be inferior to treatment with diclofenac, or the combination of both. Primary outcome will be between-group differences in decrease in pain, measured with Numerical Rating Scales at baseline and at 90 minutes after study drug administration. Secondary outcomes are Numerical Rating Scales at 30 and 60 minutes and measured frequently during three consecutive days after discharge; occurrence of adverse effects; patient satisfaction and an analysis of quality of life and cost-effectiveness. Recruitment started July 2013 and is expected to last a year.

DISCUSSION

With this multi-center randomized clinical trial we will investigate whether treatment with paracetamol alone is not inferior to diclofenac alone or a combination of both drugs in adult patients with acute musculoskeletal trauma. The main relevance of the trial is to demonstrate the benefits and risks of three commonly used treatment regimens for musculoskeletal trauma. Data that lead to the prevention of severe Non-Steroidal Anti-Inflammatory Drugs-related adverse effects might be gathered.

TRIAL REGISTRATION

Dutch Trial Register (http://www.trialregister.nl): NTR3982.EudraCT database (http://www.clinicaltrialsregister.eu): 201300038111.

Naproxen Twice Daily Versus as Needed (PRN) Dosing: Efficacy and Tolerability for Treatment of Acute Ankle Sprain, a Randomized Clinical Trial

Purpose

This study was conducted to compare the efficacy and safety of naproxen 500 mg twice daily (BID) versus naproxen 500 mg as needed (PRN) for treatment of ankle sprain.

Methods

In this seven-day, randomized, parallel group trial, 135 patients with ankle sprain occurring less than 48 hours prior to the first dose of study medication were randomized to receive naproxen 500 mg BID (67 patients) and naproxen 500 mg as needed (PRN) (68 patients). The ankle pain was assessed at rest and on full weight bearing using Numeric Rating Scale (NRS) from 0 (no pain) to 10 (the worst imaginable pain). Ankle swelling was assessed as a 4-point scale ranging from 0 (no swelling) to 3 (severe swelling) rated by the investigator. The primary efficacy end point was the patient's assessment of ankle pain via NRS and the degree of swelling on day seven.

Results

Results showed a significant decrease in pain on weight bearing, pain at rest and the extent of swelling (P<0.001) in both groups, but there was no substantial difference between the two groups (P>0.05) after seven days. Assessing the safety profile of the two different dosing, 13.3% of the naproxen BID group and 6.7% of the as needed group had adverse events, showing that the as needed regimen was safer (P<0.001).

Conclusion

Results showed that naproxen as needed may reduce the pain and edema of the sprained ankle with no significant difference compared to the BID regimen, while it possesses better safety profile and lower total drug use.

What do we (not) know about how paracetamol (acetaminophen) works?

WHAT IS KNOWN AND BACKGROUND

Although paracetamol (acetaminophen), N-(4-Hydroxyphenyl)acetamide, is one of the world's most widely used analgesics, the mechanism by which it produces its analgesic effect is largely unknown. This lack is relevant because: (i) optimal pain treatment matches the analgesic mechanism to the (patho)physiology of the pain and (ii) modern drug discovery relies on an appropriate screening assay.

OBJECTIVE

To review the clinical profile and preclinical studies of paracetamol as means of gaining insight into its mechanism of analgesic action.

METHODS

A literature search was conducted of clinical and preclinical literature and the information obtained was organized and reviewed from the perspective of its contribution to an understanding of the mechanism of analgesic action of paracetamol.

RESULTS

Paracetamol's broad spectrum of analgesic and other pharmacological actions is presented, along with its multiple postulated mechanism(s) of action. No one mechanism has been definitively shown to account for its analgesic activity.

WHAT IS NEW AND CONCLUSION

Further research is needed to uncover the mechanism of analgesic action of paracetamol. The lack of this knowledge affects optimal clinical use and impedes drug discovery efforts.

Nonsteroidal antiinflammatory drugs (NSAIDs) and paracetamol for acute musculoskeletal injuries: physiotherapists' understanding of which is safer, more effective, and when to initiate treatment

Physiotherapists are primary care practitioners, and are often the first health professional to consult with patients presenting with acute sprains or strains, and such patients may ask for advice regarding medications. Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) are readily available without a prescription and are commonly used by patients. The aim of this study was to investigate New Zealand physiotherapists' knowledge regarding the comparative safety, effectiveness, and appropriate timing of paracetamol and NSAIDs for acute musculoskeletal sprains and strains. A questionnaire was mailed to all members of the New Zealand Society of Physiotherapists currently practicing in the field of musculoskeletal physiotherapy (n = 948). Of 278 respondents (29.3%), just over half (52%) thought that NSAIDs were more effective than paracetamol in the treatment of sprains and strains. Almost half (45%) believed that NSAIDs should be withheld because of the potential for interrupting the beneficial role of inflammation in healing and that NSAIDs could increase bleeding into the injured tissue. In contrast, the majority of respondents (81%) recognised that there was no need to withhold paracetamol in the initial postinjury period. Knowledge regarding safety, effectiveness, and risks of paracetamol and NSAIDs may assist physiotherapists to recommend appropriate management of acute musculoskeletal injuries, within regulatory boundaries.

Oral cyclo-oxygenase 2 inhibitors versus other oral analgesics for acute soft tissue injury: systematic review and meta-analysis

BACKGROUND

Acute soft tissue injuries are common and carry significant societal costs. Cyclo-oxygenase 2 (COX-2) inhibitors (coxibs), non-selective nonsteroidal anti-inflammatory drugs (NSAIDs) and other analgesics are used to treat acute soft tissue injuries, with ongoing debate about their analgesic efficacy, effects on tissue healing and adverse effects (AEs).

OBJECTIVES

To systematically review the evidence comparing oral coxibs with other oral analgesics for acute soft tissue injuries, using the outcomes: pain, swelling, function and AEs.

METHODS

The following databases were searched: MEDLINE, EMBASE, Cochrane CENTRAL, CINAHL, AMED, PEDro and SPORTDiscus. Further studies were sought through clinical trials registries, dissertations, correspondence with pharmaceutical companies and manual searches of relevant journals. There was no language restriction.

DEFINITIONS

'Coxibs' were defined as drugs that inhibit COX-2 >5-fold more than COX-1; 'acute' was defined as injury occurring within 48 hours of enrollment; 'soft tissue injury' was defined as closed injuries to upper or lower limb soft tissues (ligaments, muscles or tendons).

STUDY SELECTION

Randomized controlled trials in humans comparing a coxib to a different class of oral analgesic agent for the treatment of acute soft tissue injuries for <30 days, and in which >or=80% of participants met the definition of acute soft tissue injury, were included. Studies were excluded if >20% of participants enrolled had back pain, cervical spine injury, repetitive strain injuries, delayed-onset muscle soreness, fractures, cartilage injury, penetrating wounds or primary inflammatory conditions (tendonitis, bursitis and arthritis). Nine out of 23 (39.1%) potentially relevant studies met the selection criteria.

DATA EXTRACTION

A standard form was used to extract data. Included studies were screened by the authors for risk of bias using the Cochrane risk of bias tool and evidence was graded for quality using the GRADE tool.

DATA SYNTHESIS

Clinical heterogeneity was minimized by application of strict selection criteria. Statistical heterogeneity was assessed using the I2 statistic and meta-analysis was undertaken if appropriate. Weighted mean difference (WMD) was used to assess pain, relative risk (RR) to assess AEs, and Peto odds ratio (OR) to assess return to function.

RESULTS

The nine RCTs evaluated in the meta-analysis included 3060 patients. Coxibs were found to be equal to NSAIDs (day 7+, n = 1884, 100 mm visual analogue scale [VAS]), WMD = 0.18 mm (95% CI -1.76, 2.13), p = 0.85 and tramadol (day 7+, n = 706, 100 mm VAS), WMD = -6.6 mm (95% CI -9.63, -3.47) [single study, difference clinically insignificant] for treating pain after soft tissue injuries. Coxibs had fewer gastrointestinal AEs than NSAIDs, even with short-term use (RR 0.59 [95% CI 0.41, 0.85], p = 0.004) [low quality evidence]. Swelling was measured in two studies with no difference being found between groups, but the presentation of the data was not sufficient to allow further analysis. Coxibs were found to be unlikely to be different to NSAIDs in helping patients return to function (OR 1.0 [95% CI 0.77, 1.3], p = 0.99); however, a single study suggested they may improve time to return to function (moderate quality evidence) and may have fewer AEs than tramadol (very low quality evidence). The risk of serious AEs with both coxibs and NSAIDs in this setting was low (but incompletely defined).

CONCLUSIONS

More studies comparing coxibs with NSAIDs and other analgesics in the setting of acute soft tissue injuries are necessary. A different review methodology would be required to answer the question of cardiovascular risk associated with short-term use of coxibs and NSAIDs.

Time to significant pain reduction following DETP application vs placebo for acute soft tissue injuries

OBJECTIVE

Nonsteroidal anti-inflammatory drugs (NSAIDs) provide fast and effective acute pain relief, but systemic administration has increased risk for some adverse reactions. The diclofenac epolamine 1.3% topical patch (DETP) is a topical NSAID with demonstrated safety and efficacy in treatment of acute pain from minor soft tissue injuries. Significant pain reduction has been observed in clinical trials within several hours following DETP application, suggesting rapid pain relief; however, this has not been extensively studied for topical NSAIDs in general. This retrospective post-hoc analysis examined time to onset of significant pain reduction after DETP application compared to a placebo patch for patients with mild-to-moderate acute ankle sprain, evaluating the primary efficacy endpoint from two nearly identical studies.

RESEARCH DESIGN AND METHODS

Data from two double-blind, randomized, parallel-group, placebo-controlled studies (N = 274) of safety and efficacy of the DETP applied once daily for 7 days for acute ankle sprain were evaluated post-hoc using statistical modeling to estimate time to onset of significant pain reduction following DETP application.

MAIN OUTCOME MEASURES

Pain on active movement on a 100 mm Visual Analog Scale (VAS) recorded in patient diaries; physician- and patient-assessed tolerability; and adverse events.

RESULTS

DETP treatment resulted in significant pain reduction within approximately 3 hours compared to placebo. Within-treatment post-hoc analysis based on a statistical model suggested significant pain reduction occurred as early as 1.27 hours for the DETP group. The study may have been limited by the retrospective nature of the analyses. In both studies, the DETP was well tolerated with few adverse events, limited primarily to application site skin reactions.

CONCLUSION

The DETP is an effective treatment for acute minor soft tissue injury, providing pain relief as rapidly as 1.27 hours post-treatment. Statistical modeling may be useful in estimating time to onset of pain relief for comparison of topical and oral NSAIDs.

Analgesics and anti-inflammatory medications in sports: use and abuse

Both acute and overuse musculoskeletal injuries are common in adolescent athletes. Pharmacologic agents including nonsteroidal anti-inflammatory drugs, acetaminophen, and topical over-the-counter agents have been shown to be effective in controlling pain, but data regarding their efficacy in expediting healing and time to recovery continue to be debated. Studies indicate that adolescents consume analgesic agents on their own and may be unaware of their potential toxicities. Data also indicate that adolescent athletes use medications in hopes of alleviating pain and allowing continuation of sports without adequate time for healing. This article reviews the mechanisms, toxicity, drug interactions, efficacy, and abuse potential of commonly used analgesic and anti-inflammatory drugs.

Efficacy and Safety of Ibuprofen and Acetaminophen in Children and Adults: A Meta-Analysis and Qualitative Review

Objective:

To evaluate the analgesic and antipyretic efficacy and safety of ibuprofen compared to acetaminophen in children and adults.

Data Sources:

Literature searches were performed using PubMed/MEDLINE (through August 2009) and EMBASE (through January 2008) and were restricted to the English language. In PubMed/MEDLINE, search terms used were ibuprofen, acetaminophen, paracetamol, clinical trials, and randomized controlled trials. EMBASE search terms included ibuprofen and acetaminophen, restricted to human and clinical trials.

Study Selection And Data Extraction:

All English-language articles identified from the data sources were reviewed. Multiple review articles were studied for any pertinent references and this yielded additional articles. Only articles that directly compared ibuprofen and acetaminophen were eligible for this review.

Data Synthesis:

Eighty-five studies that directly compared ibuprofen to acetaminophen were identified; 54 contained analgesic efficacy data, 35 contained antipyretic/temperature reduction data, and 66 contained safety data (some articles contained more than 1 type of data). Qualitative review of the literature revealed that, for the most part, ibuprofen was more efficacious than acetaminophen for the treatment of pain and fever in both pediatric and adult populations, and that these 2 drugs were equally safe. Meta-analyses on the subset of randomized clinical trial articles that reported sufficient quantitative information to calculate either an odds ratio (adverse event [AE]) or standardized mean difference (pain and fever) confirmed the qualitative results for adult (standardized mean difference [SMD] 0.69; 95% CI 0.57 to 0.81) and pediatric (SMD 0.28; 95% CI 0.10 to 0.46) pain at 2 hours postdose and pediatric fever (SMD 0.26; 95% CI 0.10 to 0.41) at 4 hours postdose. Conclusions regarding adult fever/temperature reduction could not be made due to a lack of evaluable data. The combined odds ratio for the proportion of adult subjects experiencing at least 1 AE slightly favored ibuprofen; however, the difference was not statistically significant (1.12; 95% CI 1.00 to 1.25). No significant difference between drugs in AE incidence was found for pediatric patients (0.82; 95% CI 0.60 to 1.12).

Conclusions:

Ibuprofen is as or more efficacious than acetaminophen for the treatment of pain and fever in adult and pediatric populations and is equally safe.

The use and abuse of painkillers in international soccer: data from 6 FIFA tournaments for female and youth players

BACKGROUND

It is known that in professional men's soccer the consumption of prescription medication is high.

PURPOSE

The intake of medication in female and adolescent male soccer players has not yet been investigated.

STUDY DESIGN

Descriptive epidemiology study.

MATERIAL

Team physicians reported 10,456 uses of medication 72 hours before each match in 2488 soccer players participating in 6 international soccer tournaments.

RESULTS

The use of a total of 6577 medical substances was reported, leading to an average intake of 0.63 substances per player per match (under-17s, 0.51; under-20s, 0.51; women, 1.0; P < or = .001 [without contraceptive medication, 0.85; P < .001]). Nonsteroidal anti-inflammatory drugs were the most commonly prescribed type of medication in all tournaments. Women's soccer had the highest percentage of players using nonsteroidal anti-inflammatory drugs per match (under-17s, 17.3%; under-20s, 21.4%; women, 30.7%; P < or = .001). Relatively few players were taking beta(2)-agonists for the treatment of asthma (under-17s, 1.3%; under-20s, 1.3%; women, 4.3%; P < or = .001).

CONCLUSION

These findings highlight the existing problem of excessive medication use in international top-level women's and male youth soccer nearly to the same extent as in men's soccer. Further steps need to be taken to understand the rationale underlying the sports physicians' practice and to plan educational programs to avoid the abuse of prescription medication.

CLINICAL RELEVANCE

Continued abuse of medication may otherwise not only negatively influence the quality of the game but also the health status of the players.

Use of prescription drugs in athletes

Although athletes are young and generally healthy, they use a variety of non-doping classified medicines to treat injuries, cure illnesses and obtain a competitive edge. Athletes and sports medicine physicians try to optimize the treatment of symptoms related to extreme training during an elite athlete's active career. According to several studies, the use of antiasthmatic medication is more frequent among elite athletes than in the general population. The type of training and the kind of sport influence the prevalence of asthma. Asthma is most common among those competing in endurance events, such as cycling, swimming, cross-country skiing and long-distance running. Recent studies show that athletes use also NSAIDs and oral antibacterials more commonly than age-matched controls, especially athletes competing in speed and power sports. Inappropriately high doses and concomitant use of several different NSAIDs has been observed. All medicines have adverse effects that may have deleterious effects on elite athletes' performance. Thus, any unnecessary medication use should be minimized in elite athletes. Inhaled beta(2)-agonists may cause tachycardia and muscle tremor, which are especially harmful in events requiring accuracy and a steady hand. In experimental animal models of acute injury, especially selective cyclo-oxygenase-2 inhibitors have been shown to be detrimental to tissue-level repair. They have been shown to impair mechanical strength return following acute injury to bone, ligament and tendon. This may have clinical implications for future injury susceptibility. However, it should be noted that the current animal studies have limited translation to the clinical setting. Adverse effects related to the CNS and gastrointestinal adverse reactions are commonly reported in connection with NSAID use also in elite athletes. In addition to the potential for adverse effects, recent studies have shown that NSAID use may negatively regulate muscle growth by inhibiting protein synthesis. Physicians and pharmacists taking care of athletes' medication need to be aware of the medicines that an athlete is taking and how those medicines interact with performance, exercise, environment and other medicines. Sport associations should repeatedly monitor not only the use of banned substances, but also the trends of use of legal medicines in athletes. Not only physicians and pharmacists, but also athletes and coaches should be better educated with respect to potential benefits and risks, and how each agent may affect an athlete's performance. The attitudes and beliefs leading to ample use of legal medicines in athletes is an interesting area of future research.