For Arthritis Pain: Diclofenac Best, Acetaminophen Worst

For Arthritis Pain: Diclofenac Best, Acetaminophen Worst

for improving both pain and function in knee or hip osteoarthritis (OA)

  • Diclofenac 150 mg/day was the most effective nonsteroidal anti-inflammatory drug (NSAID), and
  • acetaminophen (Tylenol, paracetamol) was least effective and should not be used in this setting

according to a new network meta-analysis published online March 17 in The Lancet.

The new report, which includes substantially more patients than the previous network meta-analysis, is likely to increase calls for reconsideration of OA treatment guidelines that position the drug as a first-line treatment.  

Guidelines in which acetaminophen is recommended as first-line treatment include those from

  • the American College of Physicians,
  • the American Pain Society, [It’s demoralizing to see on this list an organization supposedly supporting pain patients]
  • the European League Against Rheumatism,
  • the American College of Rheumatology,
  • the Osteoarthritis Research Society International, and
  • the UK National Institute for Health and Care Excellence.

So these guidelines are all specifically WRONG. A patient depending on acetaminophen to reduce their arthritis pain will suffer fatal toxicity before their pain is relieved.

That these less significant guidelines can be so completely wrong casts doubt of the validity of other guidelines, like the one for opioid prescribing.

74 RCTs comprising 58,556 patients were ultimately included in the analysis.

Among approved maximal daily doses,

  • diclofenac 150 mg/day and
  • etoricoxib 60 mg/day

were the most effective at reducing pain, both with 100% probability of reaching the minimum clinically important difference.

Four other treatments had a 95% probability of reaching the prespecified threshold for clinically significant impact:

  • etoricoxib 30 mg/day and 90 mg/day, and
  • rofecoxib 25 mg/day and 50 mg/day.

The authors noted that etoricoxib is less available than diclofenac because it has marketing approval in fewer countries.

This would make me suspect that etoricoxib might be harmfull

Five treatments were not superior to placebo using the data available:

  • acetaminophen < 2000 mg/day and 3000 mg/day,
  • diclofenac 70 mg/day,
  • naproxen 750 mg/day, and
  • ibuprofen 1200 mg/day.

paracetamol had nearly a null effect on pain symptoms at various doses

NSAID efficacy generally varied with dose, but acetaminophen was ineffective at all doses tested.

In a press statement, Dr Trelle said, “NSAIDs are usually only used to treat short-term episodes of pain in osteoarthritis because the side-effects are thought to outweigh the benefits when used longer term.

Because of this, paracetamol is often prescribed to manage long-term pain instead of NSAIDs.

However, our results suggest that paracetamol at any dose is not effective in managing pain in osteoarthritis, but that certain NSAIDs are effective and can be used intermittently without paracetamol.”

Dr Moore and colleagues concluded, “The most remarkable result is that paracetamol does not seem to confer any demonstrable effect or benefit in osteoarthritis, at any dose. This finding is not entirely unexpected. Paracetamol has been on the market for as long as most of us remember.

Its efficacy has never been properly established or quantified in chronic diseases, and is probably not as great as many would believe. Its safety is also questioned, not just in overdose.”  

More posts on the dangers of acetaminophen/Tylenol and other NSAIDs:

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