Use Paracetamol to treat OA pain, says global expert

November 07, 1999

November 8, 1999 - Paracetamol, in doses of up to 4000 mg/day, is still the first-line drug of choice for the management of the pain of osteoarthritis (OA), despite the recent emergence of new symptomatic treatments, according to Professor Kenneth Brandt, Head of the Rheumatology Division at Indiana University School of Medicine, USA. This was the general consensus reached by global OA experts at an International Symposium held today in Sydney, Australia.

Delegates at the 'Clinical Consensus - An International Update on Paracetamol' symposium in Sydney Australia, heard Professor Brandt outline the rationale behind the choice of paracetamol.

"In the past, treatment of OA was most often initiated with the prescription of non-steroidal anti-inflammatory drugs (NSAIDs)," said Professor Brandt. "However, evidence suggests that these drugs offer no advantage over simple analgesics, such as paracetamol in OA. Furthermore, NSAID-related adverse gastrointestinal (GI) effects are now recognised as a serious problem." In the US each year among people over the age of 65, there are 40,000 hospitalisations and 3000 deaths attributable to NSAID associated GI catastrophes.

Professor Brandt summarised the evidence that led to the recommendation of paracetamol as the first-line drug of choice in OA management:"In part because of their GI toxicity, which is dose-dependent, it is suggested that NSAIDs be used in the lowest possible dose for the shortest possible time. Clinical studies have shown that low analgesic doses of NSAIDs are often as effective as higher anti-inflammatory doses, which raises a question over the wisdom of placing patients on treatments which increase their risk of GI events without demonstrable superior efficacy. Furthermore, in clinical practice, only 15% of patients being treated for OA pain with an NSAID are still on the same NSAID at the end of the year, as a result of lack of efficacy, GI side effects or other events," continued Professor Brandt. Patient satisfaction with chronic NSAID use in OA is simply not very high.

"In OA, it has been shown that patients who take a simple analgesic, like paracetamol, as an adjunct to a comprehensive programme of non-pharmacologic measures, like weight-loss (if the patient is obese), exercise to strengthen the muscles around the joint and application of joint-protection principles, can often manage their condition adequately, without the need for additional drug-treatment. Indeed, as many as 50% of OA patients can achieve adequate symptomatic relief with these measures," he said. This recommendation reflects global medical opinion and guidelines on OA management from a number of professional bodies around the world including the American College of Rheumatology.1 2

The recent emergence of newer 'GI-tolerant' NSAIDs that specifically inhibit cyclo-oxygenase 2 (COX 2) has particularly focused attention on the GI toxicity associated with conventional NSAIDs. However, the place of these new drugs in OA management is not yet fully established, said Professor Brandt: "The COX 2s are clearly safer for the stomach than conventional NSAIDs in endoscopy studies, but it has yet to be shown that they will be associated with a lower rate of clinically important GI catastrophes such as haemorrhage, perforation, obstruction than conventional NSAIDs. They also have their own spectrum of side-effects and, it is important to note, that their efficacy in palliating OA pain is no greater than existing NSAIDs."


1. Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis. Part I. Osteoarthritis of the hip. American College of Rheumatology. Arthritis Rheum 1995; 38: 1535-1540.

2. Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee. American College of Rheumatology. Arthritis Rheum 1995; 38: 1541-1546.
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