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Cao Z, Han K, Lu H, Illangamudalige S, Shaheed CA, Chen L, McLachlan AJ, Patanwala AE, Maher CG, Lin CWC, March L, Ferreira ML, Mathieson S. Paracetamol Combination Therapy for Back Pain and Osteoarthritis: A Systematic Review and Meta-Analyses. Drugs 2024; 84:953-967. [PMID: 38937394 PMCID: PMC11343817 DOI: 10.1007/s40265-024-02065-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND AND OBJECTIVE Although paracetamol (acetaminophen) combined with other analgesics can reduce pain intensity in some pain conditions, its effectiveness in managing low back pain and osteoarthritis is unclear. This systematic review investigated whether paracetamol combination therapy is more effective and safer than monotherapy or placebo in low back pain and osteoarthritis. METHODS Online database searches were conducted for randomised trials that evaluated paracetamol combined with another analgesic compared to a placebo or the non-paracetamol ingredient in the combination (monotherapy) in low back pain and osteoarthritis. The primary outcome was a change in pain. Secondary outcomes were (serious) adverse events, changes in disability and quality of life. Follow-up was immediate (≤ 2 weeks), short (> 2 weeks but ≤ 3 months), intermediate (> 3 months but < 12 months) or long term (≥ 12 months). A random-effects meta-analysis was conducted. Risk of bias was assessed using the original Cochrane tool, and quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS Twenty-two studies were included. Pain was reduced with oral paracetamol plus a non-steroidal anti-inflammatory drug (NSAID) at immediate term in low back pain (paracetamol plus ibuprofen vs ibuprofen [mean difference (MD) - 6.2, 95% confidence interval (CI) -10.4 to -2.0, moderate evidence]) and in osteoarthritis (paracetamol plus aceclofenac vs aceclofenac [MD - 4.7, 95% CI - 8.3 to - 1.2, moderate certainty evidence] and paracetamol plus etodolac vs etodolac [MD - 15.1, 95% CI - 18.5 to - 11.8; moderate certainty evidence]). Paracetamol plus oral tramadol reduced pain compared with placebo at intermediate term for low back pain (MD - 11.7, 95% CI - 19.2 to - 4.3; very low certainty evidence) and osteoarthritis (MD - 6.8, 95% CI - 12.7 to -0.9; moderate certainty evidence). Disability scores improved in half the comparisons. Quality of life was infrequently measured. All paracetamol plus NSAID combinations did not increase the risk of adverse events compared to NSAID monotherapy. CONCLUSIONS Low-to-moderate quality evidence supports the oral use of some paracetamol plus NSAID combinations for short-term pain relief with no increased risk of harm for low back pain and osteoarthritis compared to its non-paracetamol monotherapy comparator.
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Affiliation(s)
- Zhiying Cao
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Kaiyue Han
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Hanting Lu
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Christina Abdel Shaheed
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia
| | - Lingxiao Chen
- Department of Orthopedics, Shandong University Centre for Orthopedics, Advanced Medical Research Institute, Qilu Hospital of Shandong University, Shandong University, Jinan, China
- Department of Biostatistics, School of Public Health, Shandong University, Jinan, China
| | - Andrew J McLachlan
- Sydney Pharmacy School, The University of Sydney, Sydney, NSW, Australia
| | - Asad E Patanwala
- Sydney Pharmacy School, The University of Sydney, Sydney, NSW, Australia
- Department of Pharmacy, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia
- Faculty of Medicine and Health, Sydney Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia
| | - Lyn March
- Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Sydney Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Stephanie Mathieson
- Faculty of Medicine and Health, Sydney Musculoskeletal Health, The University of Sydney, Sydney, NSW, Australia.
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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Lim WB, Al-Dadah O. Conservative treatment of knee osteoarthritis: A review of the literature. World J Orthop 2022; 13:212-229. [PMID: 35317254 PMCID: PMC8935331 DOI: 10.5312/wjo.v13.i3.212] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/29/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
Knee osteoarthritis (KOA) is a common chronic debilitating disease with an estimated prevalence of 23.9% in the general adult population. The condition is characterised by joint pain, functional impairment and significant reduction in quality of life. Management for KOA can generally be divided into conservative (non-operative) and surgical (operative) measures. Conservative management broadly compromises pharmacological and non-pharmacological options and is conventionally the first line treatment to avoid or delay the need for surgical management. The aim of this study is to provide an overview of the current recommendations, efficacy and safety profile of different conservative treatments through a review of the literature.
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Affiliation(s)
- Wei Boon Lim
- The Medical School, Newcastle University, Newcastle-upon-Tyne NE2 4HH, United Kingdom
| | - Oday Al-Dadah
- Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Tyneside NE34 0PL, United Kingdom
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne NE2 4HH, United Kingdom
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Parry EL, Thomas MJ, Peat G. Defining acute flares in knee osteoarthritis: a systematic review. BMJ Open 2018; 8:e019804. [PMID: 30030311 PMCID: PMC6059300 DOI: 10.1136/bmjopen-2017-019804] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 04/10/2018] [Accepted: 05/15/2018] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To identify and critically synthesise definitions of acute flares in knee osteoarthritis (OA) reported in the medical literature. DESIGN Systematic review and narrative synthesis. We searched Medline, EMBASE, Web of science and six other electronic databases (inception to July 2017) for original articles and conference abstracts reporting a definition of acute flare (or synonym) in humans with knee OA. There were no restrictions by language or study design (apart from iatrogenic-induced flare-ups, eg, injection-induced). Data extraction comprised: definition, pain scale used, flare duration or withdrawal period, associated symptoms, definition rationale, terminology (eg, exacerbation or flare), baseline OA severity, age, gender, sample size and study design. RESULTS Sixty-nine articles were included (46 flare design trials, 17 observational studies, 6 other designs; sample sizes: 15-6085). Domains used to define flares included: worsening of signs and symptoms (61 studies, 27 different measurement tools), specifically increased pain intensity; minimum pain threshold at baseline (44 studies); minimum duration (7 studies, range 8-48 hours); speed of onset (2 studies, defined as 'sudden' or 'quick'); requirement for increased medication (2 studies). No definitions included activity interference. CONCLUSIONS The concept of OA flare appears in the medical literature but most often in the context of flare design trials (pain increases observed after stopping usual treatment). Key domains, used to define acute events in other chronic conditions, appear relevant to OA flare and could provide the basis for consensus on a single, agreed definition of 'naturally occurring' OA flares for research and clinical application. PROSPERO REGISTRATION NUMBER CRD42014010169.
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Affiliation(s)
- Emma L Parry
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Martin J Thomas
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - George Peat
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
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Patel PB, Patel TK. Efficacy and safety of aceclofenac in osteoarthritis: A meta-analysis of randomized controlled trials. Eur J Rheumatol 2017; 4:11-18. [PMID: 28293447 DOI: 10.5152/eurjrheum.2017.160080] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/01/2016] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To analyze the effects on pain, function, and safety of aceclofenac compared with other nonsteroidal anti-inflammatory drugs (NSAIDs) or pain relief medications in patients with osteoarthritis. MATERIAL AND METHODS Two investigators independently searched the database. We included randomized controlled trials evaluating efficacy and/or safety of aceclofenac compared with control interventions (NSAIDs or acetaminophen) in patients with osteoarthritis. We did not include placebo, opioid analgesics, NSAID combinations, and topical analgesics for the control groups. We summarized the efficacy data as standardized mean differences (SMD) with 95% confidence intervals (CI) and safety outcomes as risk ratios (RR) with 95% CI using the inverse variance random effect model. We assessed the heterogeneity by the I2 test. We used the GRADE approach to evaluate the quality of the evidence for all outcome parameters. RESULTS We included 9 trials (8 double blind and 1 single blind) that evaluated pain (7 trials), function (8 trials) and safety (7 trials). We observed no significant difference in pain reduction between aceclofenac and control interventions [SMD: -0.30 (-0.62, 0.01); I2=88%; GRADE evidence- low]. Aceclofenac was more beneficial than control interventions in improving physical function [SMD: -0.27 (-0.50, -0.03); I2=88%; GRADE evidence- low]. We observed less gastrointestinal adverse events for aceclofenac than in control interventions [RR 0.69 (95% CI: 0.57, 0.83); I2=12%; GRADE evidence- moderate]. We observed no difference in overall adverse events occurrence and dropout rate between aceclofenac and control interventions. CONCLUSION We observed that aceclofenac was beneficial over control analgesics for function improvement and to minimize gastrointestinal adverse events. Our findings could be biased due to the heterogeneity of the sample, the fact that the trials were small and methodological issues.
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Affiliation(s)
- Parvati B Patel
- Department of Pharmacology, GMERS Medical College, Gotri, Gujarat, India
| | - Tejas K Patel
- Department of Pharmacology, GMERS Medical College, Gotri, Gujarat, India
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Balmaceda CM. Clinical trial data in support of changing guidelines in osteoarthritis treatment. J Pain Res 2014; 7:211-8. [PMID: 24748817 PMCID: PMC3990388 DOI: 10.2147/jpr.s45321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Goals for the management of osteoarthritis (OA) emphasize pain relief, reduction of inflammation, and improvement in functioning. Among pharmacological pain management interventions, nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently recommended as the most effective treatment option for OA. However, the use of traditional oral NSAIDs is associated with risk of serious adverse events involving the gastrointestinal, cardiovascular, and renal systems. Topical NSAIDs are an alternative with well-established tolerability and efficacy in the treatment of OA of the knee or hand. While the management of OA pain is evolving toward the more widespread use of topical NSAIDs, some OA management guidelines have yet to incorporate these agents in their recommendations. This review examines the efficacy and tolerability of topical NSAIDs, their current placement in OA management guidelines, and their potential role in enabling pain specialists to provide individualized care for their patients with OA.
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van Laar M, Pergolizzi JV, Mellinghoff HU, Merchante IM, Nalamachu S, O'Brien J, Perrot S, Raffa RB. Pain treatment in arthritis-related pain: beyond NSAIDs. Open Rheumatol J 2012; 6:320-30. [PMID: 23264838 PMCID: PMC3527878 DOI: 10.2174/1874312901206010320] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 10/22/2012] [Accepted: 10/26/2012] [Indexed: 12/14/2022] Open
Abstract
Managing pain from chronic conditions, such as, but not limited to, osteoarthritis and rheumatoid arthritis, requires the clinician to balance the need for effective analgesia against safety risks associated with analgesic agents. Osteoarthritis and rheumatoid arthritis pain is incompletely understood but involves both nociceptive and non-nociceptive mechanisms, including neuropathic mechanisms. Prevailing guidelines for arthritis-related pain do not differentiate between nociceptive and non-nociceptive pain, sometimes leading to recommendations that do not fully address the nature of pain. NSAIDs are effective in treating the nociceptive arthritis-related pain. However, safety concerns of NSAIDs may cause clinicians to undertreat arthritis-related pain. In this context, combination therapy may be more appropriate to manage the different pain mechanisms involved. A panel convened in November 2010 found that among the currently recommended analgesic products for arthritis-related pain, fixed-low-dose combination products hold promise for pain control because such products allow lower doses of individual agents resulting in decreased toxicity and acceptable efficacy due to synergy between the individual drugs. Better evidence and recommendations are required to improve treatment of chronic arthritis-related pain.
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Affiliation(s)
- Mart van Laar
- Arthritis Center Twente (MST & UT), Enschede, The Netherlands
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Pergolizzi JV, van de Laar M, Langford R, Mellinghoff HU, Merchante IM, Nalamachu S, O'Brien J, Perrot S, Raffa RB. Tramadol/paracetamol fixed-dose combination in the treatment of moderate to severe pain. J Pain Res 2012; 5:327-46. [PMID: 23055775 PMCID: PMC3442743 DOI: 10.2147/jpr.s33112] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Pain is the most common reason patients seek medical attention and pain relief has been put forward as an ethical obligation of clinicians and a fundamental human right. However, pain management is challenging because the pathophysiology of pain is complex and not completely understood. Widely used analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol (acetaminophen) have been associated with adverse events. Adverse event rates are of concern, especially in long-term treatment or at high doses. Paracetamol and NSAIDs are available by prescription, over the counter, and in combination preparations. Patients may be unaware of the risk associated with high dosages or long-term use of paracetamol and NSAIDs. Clinicians should encourage patients to disclose all medications they take in a “do ask, do tell” approach that includes patient education about the risks and benefits of common pain relievers. The ideal pain reliever would have few risks and enhanced analgesic efficacy. Fixed-dose combination analgesics with two or more agents may offer additive or synergistic benefits to treat the multiple mechanisms of pain. Therefore, pain may be effectively treated while toxicity is reduced due to lower doses. One recent fixed-dose combination analgesic product combines tramadol, a centrally acting weak opioid analgesic, with low-dose paracetamol. Evidence-based guidelines recognize the potential value of combination analgesics in specific situations. The current guideline-based paradigm for pain treatment recommends NSAIDs for ongoing use with analgesics such as opioids to manage flares. However, the treatment model should evolve how to use low-dose combination products to manage pain with occasional use of NSAIDs for flares to avoid long-term and high-dose treatment with these analgesics. A next step in pain management guidelines should be targeted therapy when possible, or low-dose combination therapy or both, to achieve maximal efficacy with minimal toxicity.
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Affiliation(s)
- Joseph V Pergolizzi
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA ; Association of Chronic Pain Patients, Houston, TX, USA
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Pareek A, Chandurkar N, Gupta A, Sirsikar A, Dalal B, Jesalpura B, Mehrotra A, Mukherjee A. Efficacy and Safety of Aceclofenac-CR and Aceclofenac in the Treatment of Knee Osteoarthritis: A 6-Week, Comparative, Randomized, Multicentric, Double-Blind Study. THE JOURNAL OF PAIN 2011; 12:546-53. [DOI: 10.1016/j.jpain.2010.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 10/13/2010] [Accepted: 10/21/2010] [Indexed: 10/18/2022]
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