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Further doubts raised over benefits of paracetamol for musculoskeletal pain

Researchers have renewed calls for an overhaul of advice on paracetamol in clinical guidelines for back pain and osteoarthritis, after finding it offers little benefit while potentially increasing the risk of liver damage.

Their study – a meta-analysis of thirteen randomised trials of paracetamol  published in the BMJ – found paracetamol was no better than placebo for pain, disability and quality of life measures in the treatment of low back pain.

For hip or knee pain osteoarthritis, paracetamol did show a statistically significant effect in reducing pain and disability in the short term – but the researchers said the changes were not clinically important.

And although no increase in adverse events was reported with paracetamol compared with placebo, the team found patients taking paracetamol were four times as likely to have abnormal findings on liver function tests.

The Australian team concluded: ‘Paracetamol is ineffective in the treatment of low back pain and provides minimal short-term benefit for people with osteoarthritis.

‘These results support the reconsideration of recommendations to use paracetamol for patients with low back pain and osteoarthritis of the hip or knee in clinical practice guidelines.’

NICE advisors on osteoarthritis clinical guidelines were recently forced to back down on proposals to remove paracetamol as a first-line option for treatment of pain, after critics raised concerns it would increase prescribing of other, potentially more harmful drugs including NSAIDs and opioids.

UK academics, including GP Dr Christian Mallen, a professor in general practice at Keele University, said the latest findings re-open the debate over pharmacological management of musculoskeletal pain, and called for a shift to non-pharmacological approaches – particularly exercise.

‘The findings… emphasis that the time has come to shift our attention away from tablets as the default option for managing chronic musculoskeletal pain,’ they wrote in an editorial alongside the BMJ paper.

NICE confirmed it would be looking at paracetamol again as part of a wider review of drugs for osteoarthritis once the UK drugs regulator, the Medicines and Healthcare Products Regulatory Agency (MHRA), has completed a review of the safety of over-the-counter analgesics, including paracetamol.

A spokesperson said: ‘NICE has decided to wait until the MHRA’s work is complete before doing a review of all pharmacological management for osteoarthritis (including paracetamol). Looking at all of the relevant painkillers together, instead of just one, will then provide a comprehensive overview of this aspect of managing osteoarthritis and allow the findings of the MHRA work to be taken into account.’

A spokesperson for the MHRA told Pulse the safety review of painkillers available over the counter was likely to be completed ‘later in the year’.

The spokesperson said: ‘The MHRA has is considering the available evidence and what, if any, changes are needed in how these medicines are used in the non-prescription setting, and will seek advice from the independent scientific advisory body, the Commission on Human Medicines.

‘It is anticipated that the review will be completed later in the year at which point the outcome will be communicated.’

BMJ 2015; available online 1 April


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Readers' comments (7)

  • Vinci Ho

    Paracetamol prescribing is the new antibiotics controversy?

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  • Shouldn't be scriptable anyway. If you need money in a dying system stop this single script and see what happens. Then stop another. But no, lets bring out 20 emollient brands and script stockings for free. But no. No one has the guts.

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  • The placebo effect is saving you many billions NHSE from upcoming anticipated referrals to pain clinic and ortgopaedics. The sword is now double edged.

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  • If paracetamol is not scriptable then you need to be able to buy sensible amounts. At the moment you can only buy them in packs of 16 and there is a limit of two packs for each person.

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  • John Glasspool

    the research is bollocks- complete and utter bollocks. Why? The evidence of my own eyes and personal pain over many years and my own total distrust of "meta-analyses"

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  • What I take from this study:
    1. paracetamol is safe in the short term (<3months) which is reassuring given concerns raised in the recent observational study http://ard.bmj.com/content/early/2015/02/09/annrheumdis-2014-206914.long
    2. If LFTs are marginally raised, remembering to ask about paracetamol
    3. In a complex area like pain, a metanalysis is unlikely to tell the whole story. Pincus et al 2004 included in the meta-analysis for example showed improvement in hip/knee pain of 18.3%
    (range 10.9–25.8%) for paracetamol and 10.2% (range
    3.7–16.4%) for placebo (tables 2A and B). The meta-analysis criteria concludes paracetamol is therefore ineffective. But for my patient an 18% improvement in pain is likely to be significant.
    The same study shows around 20- 30% of patients preferred taking paracetamol to an NSAID.

    So:
    I know pain relief is only part of a solution
    Different medications suit different people
    If Paracetamol helps enough is safe to prescribe for 3 months
    if I could prescribe placebos/enhance the placebo effect it it would be really helpful

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  • April fools everyone! Paracetamol does work of course! love the meta-analysis team xxx

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