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NICE warns against prescribing paracetamol for osteoarthritis

NICE has warned GPs against prescribing paracetamol for patients with osteoarthritis after its experts said they were ‘extremely concerned’ about the links of higher doses to cardiovascular, gastrointestinal and renal adverse events.

Draft updated guidance on osteoarthritis has warned of the potential side effects of paracetamol and said it has ‘limited benefit’. When used, it should be the ‘lowest effective dose’ for the ‘shortest possible time’ and clinicians should be particularly cautious of using it in combination with an oral NSAID, the guidance added.  

Experts welcomed the move but criticised the guidance for not also reviewing the use of opioids, which was a ‘major failing’.

The consultation, due for release in 2014, said: ‘Do not routinely offer paracetamol for the management of osteoarthritis. Be aware of the potential side effects and limited benefit. If prescribing paracetamol, use it at the lowest effective dose for the shortest possible period of time and use cautiously if prescribing in combination with an oral NSAID.’

It added: ‘There is uncertainty about the clinical benefit and risks of side effects when paracetamol is taken intermittently or for the management of exacerbations of osteoarthritis.’

The explanatory section of the guidance said that the guideline development group (GDG) was ‘extremely concerned’ about its links to possible fatal events.

It said: ‘The group were extremely concerned about the very definite trend from observational data linking paracetamol at increasing doses to cardiovascular (fatal/non fatal MI, stroke, heart failure), gastrointestinal (upper and lower) and renal adverse events.

‘The GDG felt that the increase in renal adverse events with long-term cumulative doses of paracetamol particularly would be a surprising finding for most clinicians and wishes to highlight this issue.’

Professor Mark Baker, director of the centre for clinical practice at NICE, added: ‘Asking people about their use of over-the-counter medicines is a further new draft recommendation.”

Dr John Dickson, a GP in Middlesbrough and community rheumatologist, was clinical advisor to the guideline development group for the 2008 NICE guidance on osteoarthritis. He welcomed the recommendation on paracetamol but said other sections of the guidance should also have been changed.

He said: ‘There is more evidence of side-effects with paracetamol  than we realised previously.

‘But one of the problems is the GDG has only been asked to look at certain sections. They were not allowed to look at opioids - a lot of which contain paracetamol. In my view, it´s a major failing of this review.’

The guideline also includes a draft recommendation that glucosamine and chondroitin products should not be offered to manage osteoarthritis as the evidence on their clinical effectiveness is very limited and uncertain.

It also also recommends that osteoarthritis can be diagnosed clinically without investigations if the patient is 45 or over and has activity-related joint pain with either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.

Dr Louise Warburton, a GPSI in rheumatology and musculoskeletal medicine in Shropshire, said this was a useful new indicator for primary care.

She added: ‘It allows the OA management pathway to be instituted for patients very early on in their disease. Traditionally GPs would wait until there was x-ray evidence of OA, but by then, treatment strategies should have started, and the best value for these interventions has been missed.’

A further guideline advised: ‘When prescribing oral analgesics, be aware of the risks, benefits and contraindications of the different drugs, and prescribe with caution in older people.’

Dr Warburton said this was particularly pertinent with the problems with diclofenac and should stop the blanket prescribing of NSAIDs by GPs without doing a proper assessment.

Dr Tom Margham, primary care lead at Arthritis Research UK and a GP in East London, said: ‘The draft guidelines make the case for more research into pharmacological and non-pharmacological treatments for osteoarthritis including the need for more studies that reflect “real life” use of therapies, or combinations of therapies, used over a significant duration of time.

‘Many GPs and patients will know the limitations of paracetamol for pain relief in osteoarthritis but are less aware of the associated long-term cardiovascular, gastrointestinal and renal risks.’


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