Aches and pains - latest recommendations

[Wetstuff]

This is a partial transcript from a medical news podcast...  it had other stuff about gastric bypass but this was the nugget.

Elizabeth: Let us turn now to Annals of Internal Medicine. This is a clinical guideline and it's taking a look at the management of acute pain from non-low back musculoskeletal injuries in adults.

Rick: We're talking about conditions that cause 65 million healthcare visits in the United States and four out of five injuries that were treated in a physician's office are musculoskeletal, so this is huge.

They did two systematic evidence reviews. They did a network meta-analysis on the comparative efficacy and safety of different treatments, and then they also looked at a systematic review on the predictors of prolonged opioid use, because that is one of the proposed treatments. I'm just going to summarize. They had four recommendations, Elizabeth.

As recommendation #1 -- so this is their highest recommendation, and it's a strong recommendation based upon moderate-certainty evidence -- that topical non-steroidal anti-inflammatory drugs, either with or without a menthol gel, as first-line therapy to reduce or relieve symptoms including pain. It improves physical function and it improves patient satisfaction. Elizabeth, I'm surprised. Let me move on, though.

Recommendation #2, moderate-certainty evidence, is that if that's unsuccessful, then oral NSAIDs have been shown to be effective, again, in reducing or relieving symptoms including pain, improving physical function, either with or without oral acetaminophen. Recommendation 2B is to use specific acupressure to reduce pain and improve physical function. It does have some benefit.

Recommendation 3 is specifically against clinicians treating people with acute pain with opioids, and that even includes Tramadol. We know that about a fourth of these patients that are treated with opioids continue to use them, either prolonged use or the large number of pills increases to opioid abuse. What are your thoughts?
Elizabeth: Well, I guess I'm glad that people are looking at this systematically and determining that these topical things are good because they have a very low possibility of deleterious effects.

Rick: They looked at major things, does it relieve pain, either within less than 2 hours or over 1 to 7 days, does it improve physical function, does it improve the patient's satisfaction? Oral medications do, but they carry some risk in terms of these NSAIDs causing acute gastritis, or ulcers, or kidney disease, or raising the blood pressure of some individuals, and the topical NSAIDs don't do that.

I was really surprised that the evidence was moderate-certainty -- a strong recommendation -- for topical NSAIDs. It's certainly going to change the recommendations I make to my patients.

Elizabeth: On that note, that's a look at this week's medical headlines from Texas Tech. I'm Elizabeth Tracey.

Rick: And I'm Rick Lange. Y'all listen up and make healthy choices.

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I'll add...

The following list is an example of NSAIDs available:

aspirin.
celecoxib (Celebrex)
diclofenac (Cambia, Cataflam, Voltaren-XR, Zipsor, Zorvolex)
diflunisal (Dolobid - discontinued brand)
etodolac (Lodine - discontinued brand)
ibuprofen (Motrin, Advil)
indomethacin (Indocin)

...note: they said; "either with or without oral acetaminophen"

..another search:

What is the difference between NSAIDs and acetaminophen? Both acetaminophen and NSAIDs reduce fever and relieve pain caused by muscle aches and stiffness, but only NSAIDs can reduce inflammation (swelling and irritation).

Tylenol is a common acetaminophen brand name.

And there are combos with Aspirin/caffeine/others...  Excedrin is a common brand name. 


Jim