Recommendations for the Use of Paracetamol in Acute and Chronic Pain
Chia Yook Chin; Keith KW Chan; Chun-Jen Liu; Harry Isbagyo; Muhaini Othman; Tran Viet Luan.
Medical Progress, Volume 37, No.17, 2010, 578-583
Although non-steroidal anti-inflammatory drugs (NSAIDs) are consumed by several million people worldwide in both acute and chronic pain settings, numerous studies have raised questions regarding the cardiovascular (CV) safety as well as the increased risks of gastrointestinal (GI) bleeding caused by these drugs, particularly with long-term usage.
A large meta-analysis demonstrated a strong association between NSAIDs and an increased risk of CV events, especially myocardial infarction.1 Other studies have provided evidence that NSAIDs may play a role in new-onset congestive heart failure and greatly increase the risk of hospitalization in those with a previous history of the disease.2,3 With regard to GI adverse events, although the risk of serious GI problems with prescribed NSAIDs is well recognised,4 these drugs also have the potential for adverse GI effects at lower, over-the-counter (OTC) doses.5
Apart from the need of a safe and effective analgesic for acute pain, there is also a need for the same to treat the chronic pain of osteoarthritis (OA). OA is associated with pain and disability, and managing this with drug therapy, especially in the elderly, is a challenge as doctors need to decide which medications provide the greatest symptom relief with the least serious adverse events.6
Paracetamol is effective when taken at recommended doses, has a good safety profile, may be used in essentially all age groups, and has fewer adverse effects than NSAIDs.7–12 Evidence also exists that it is effective in relieving the chronic pain of OA and is well tolerated over a long term.13,14
Two recent Cochrane reviews have shown that paracetamol is effective for acute pain.15,16
- Kearney PM, Baigent C, Godwin J, et al. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials.BMJ 2006;332:1302– 1308.
- Huerta C, Varas-Lorenzo C, Castellsague J, et al. Non-steroidal anti-inflammatory drugs and risk of first hospital admission for heart failure in the general population. Heart 2006;92:1610–1615.
- Page J, Henry D. Consumption of NSAIDs and the development of congestive heart failure in elderly patients: an underrecognized public health problem. Arch Intern Med 2000;160:777–784.
- Tarone RE, Blot WJ, McLaughlin JK. Nonselective non-aspirin nonsteroidal anti-inflammatory drugs and gastrointestinal bleeding: relative and absolute risk estimates from recent epidemiologic studies. Am J Ther 2004;11:17–25.
- Singh G. Gastrointestinal complications of prescription and over-the-counter nonsteroidal anti-inflammatory drugs: a view from the ARAMIS database. Arthritis, Rheumatism, and Aging Medical Information System. Am J Ther 2000;7:115–121.
- Chou R, Helfand M, Peterson K, et al. Comparative effectiveness and safety of analgesics for osteoarthritis.Agency for Healthcare Research and Quality. Available at http://www. effectivehealthcare.ahrq.gov/index.cfm/search-for-guidesreviews-and-reports. Accessed 9 November 2009.
- American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis Rheum 2000;43:1905–1915.
- Jordan KM, Arden NK, Doherty M, et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003;62:1145–1155.
- Zhang W, Doherty M, Arden N, et al. EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2005;64:669–681.
- Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2007;66:377–388.
- Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008;16:137–162.
- National Collaborating Centre for Chronic Conditions. Osteoarthritis: the care and management of osteoarthritis in adults. NICE clinical guideline 59. Available at http://www. nice.org.uk/CG59. Accessed 9 November 2009.
- Nikles CJ, Yelland M, Del Mar C, et al. The role of paracetamol in chronic pain: an evidence-based approach. Am J Ther 2005;12:80–91.
- Temple AR, Benson GD, Zinsenheim JR, etla. Multicenter, randomized, double-blind, active-controlled, parallel-group trial of the long-term (6-12 months) safety of acetaminophen in adult patients with osteoarthritis. Clin Ther 2006;28:222–235.
- Toms L, McQuay HJ, Derry S, et al. Single dose oral paracetamol (acetaminophen) for postoperative pain in adults. Cochrane Database Syst Rev 2008;(4):CD004602.
- Weil K, Hooper L, Afzal Z, et al. Paracetamol for pain relief after surgical removal of lower wisdom teeth. Cochrane Database Syst Rev 2007;(3):CD004487.