Should topical nonsteroidal anti-inflammatory drugs be used to treat acute musculoskeletal conditions?
Date First Published:
June 10, 2018
Last Updated:
June 10, 2018
Report by:
Ashlee Edgell MD, Matt Singh MD, Senior EM resident, EM faculty (Spectrum Health/Michigan State University Emergency Medicine Residency Program)
Search checked by:
Jeffrey Jones MD, Spectrum Health/Michigan State University Emergency Medicine Residency Program
Three-Part Question:
In [adult patients with musculoskeletal conditions] do [topical nonsteroidal anti-inflammatory drugs compared to placebo] provide [safe and effective pain relief]?
Clinical Scenario:
A 48-year-old male presents to the emergency department (ED) with a left ankle injury. X-rays showed no acute fracture. The patient has a history of chronic alcohol abuse, hepatitis C, opioid abuse, and gastric ulcers. Therefore, he is unable to take acetaminophen, nonsteroidal anti-inflammatory drugs (NSAID), or narcotics.
Search Strategy:
Medline 1966-05/18 using PubMed, CINAHL, Cochrane Library (2018), and Embase.
Search Details:
[(exp Anti-Inflammatory Agents, Non-Steroidal/administration and dosage) AND (exp Pain/drug therapy) AND (exp topical)]. Limit to humans and English language.
Outcome:
77 studies were identified; one systematic review from the Cochrane Library addressed the clinical question. This review considered 61 clinical trials for inclusion. Since its publication, there have been two additional prospective RCTs published.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Topical Ketoprofen Versus Placebo in Treatment of Acute Ankle Sprain in the Emergency Department Seriken M, Eken C, Elicabuk H. 2016 Turkey | 100 ED patients with ankle sprain randomized to 2.5% ketoprofen gel (2g) or placebo. | RCT | Pain reduction at 15 minutes using a visual analog scale (VAS) | Ketoprofen 27 vs. placebo (p<0.0001) | Superiority trial, small sample size, no block randomization, no data on efficacy after 30 min. |
| Pain reduction at 30 minutes (VAS) | Ketoprofen 42 vs. placebo 20 (p<0.0001) | ||||
| Efficacy and safety of topical diclofenac/menthol gel for ankle sprain: A randomized, double-blind, placebo- and active-controlled trial Lai PM, Collaku A, Reed K 2017 Germany | 385 ED patients with ankle sprain randomized to 1% diclofenax/3% menthol, 1% diclofenac, 3% menthol, or placebo | RCT | Pain intensity on movement from 24 to 72 hours using area under the curve (AUC); secondary outcomes included pain relief, swelling, and complete recovery | No statistically significant difference in pain reduction as measured by the adjusted mean AUC or secondary outcomes | Long interval between injury and treatment (up to 24 hours); no stratification by time since injury; 40 patients with protocol violations |
| Topical NSAIDs for acute musculoskeletal pain in adults Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ 2015 United Kingdom | 61 RCT studies (8386 participants) of adults presenting with acute musculoskeletal pain | Systematic review | Number needed to treat (NNT) to achieve a 50% reduction in pain or equivalent measure within 1 week | Diclofenac gel NNT 1.8; Ibuprofen gel NNT 3.9; Ketoprofen gel NNT 2.5 | There were insufficient data to compare reliably individual topical NSAIDs with each other or the same oral NSAID; primary outcome of clinical success was not always well-defined, and was measured using different scales. |
Author Commentary:
Oral analgesics are commonly prescribed for the treatment of acute pain, but these agents often produce adverse systemic effects. Topical administration of NSAIDs can produce clinically effective drug concentrations at a peripherally located site of injury or inflammation, minimizing systemic absorption and adverse effects. The available evidence suggests that topical NSAIDs can be recommended for short-term pain relief in patients with acute soft tissue injuries. Gel formulations of diclofenac, ibuprofen, and ketoprofen, seem to provide the best results. Local skin reactions were generally mild and transient, and did not differ from placebo
Bottom Line:
Topical NSAIDS provide adequate pain relief in acute musculoskeletal sprains, with a high safety profile.
References:
- Seriken M, Eken C, Elicabuk H. . Topical Ketoprofen Versus Placebo in Treatment of Acute Ankle Sprain in the Emergency Department
- Lai PM, Collaku A, Reed K. Efficacy and safety of topical diclofenac/menthol gel for ankle sprain: A randomized, double-blind, placebo- and active-controlled trial
- Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults