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Year : 2014  |  Volume : 60  |  Issue : 2  |  Page : 212

Paracetamol in osteoarthritis: NICE guidelines or not so nice

Department of Pharmacology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India

Date of Web Publication13-May-2014

Correspondence Address:
Dr. A Kamath
Department of Pharmacology, Kasturba Medical College, Manipal University, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0022-3859.132370

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How to cite this article:
Kamath A. Paracetamol in osteoarthritis: NICE guidelines or not so nice. J Postgrad Med 2014;60:212

How to cite this URL:
Kamath A. Paracetamol in osteoarthritis: NICE guidelines or not so nice. J Postgrad Med [serial online] 2014 [cited 2023 Jun 9];60:212. Available from:


Paracetamol is widely recommended as the analgesic of first choice in the treatment of mild to moderate osteoarthritis (OA). [1] The relatively lesser efficacy of paracetamol in comparison to traditional nonsteroidal anti-inflammatory drugs is offset by its better safety profile. However, the recent draft guideline of National Institute for Health and Care Excellence (NICE) on management of osteoarthritis has cast a doubt on both the safety and efficacy profile of paracetamol. The draft guideline recommends the use of paracetamol at the lowest effective dose for the shortest possible period of time. [2] This is based on the evaluation of data published after the year 2005 (published after the last NICE guidelines on osteoarthritis). The efficacy assessment was based on the data from nine randomized controlled trials comparing paracetamol (dose of >3 g/day) to placebo. No clinically important difference was demonstrated between paracetamol 3-4 g/day and placebo across all outcomes for knee OA and mixed joint OA (hip/knee). [2] Paracetamol was also found not to be cost-effective due to marginally higher cost of drug acquisition and marginally lower quality adjusted life years compared to no treatment. [2] The safety data were based on observational studies with long-term follow-up ranging from 30 days to 20 years. Increasing doses of paracetamol was associated with increase in cardiovascular (fatal/nonfatal myocardial infarction, stroke, heart failure), gastrointestinal (upper and lower), and renal adverse events. [2] The use of paracetamol in combination with traditional NSAIDs has been shown to increase the risk of gastrointestinal bleeding compared to either agent alone in elderly patients. [3] The frequency of adverse events with regard to intermittent use of paracetamol or use of lower doses is not known. The aforementioned findings considerably restrict the analgesic options for long-term pain management in OA. Moreover, paracetamol use in general population was evaluated in the observational studies that looked into the frequency of adverse effects on long-term follow-up. Hence, the use of paracetamol for long-term pain management in other conditions also needs to be reconsidered. While the efficacy of paracetamol was known to be modest, the conclusions arrived based on the aforementioned studies suggest that paracetamol is less efficacious and more harmful than known earlier. The overall quality of the observational studies included in the review were judged to be of very low quality. [2] Representatives from the public health sectors and pharmaceutical companies alike have raised concerns about the possible increase in the usage of NSAIDs and opiates that carry a definite increased risk of adverse health outcomes compared to paracetamol. [4] Taking into consideration the comments of the stakeholders, the fact that the guideline review was limited in its scope and that a full review of the pharmacological management of osteoarthritis is yet to be done, NICE has retained the earlier guideline (2008) recommendations about use of paracetamol for the time being until the full review report is available. [5] Irrespective of the final recommendations, the need to impress upon the patients the role of nonpharmacological measures in knee osteoarthritis becomes all the more important than ever before.

 :: References Top

1.Flood J. The role of acetaminophen in the treatment of osteoarthritis. Am J Manag Care 2010;16(Suppl Management):S48-54.  Back to cited text no. 1
2.National Institute for Health and Care Excellence (2013). [Osteoarthritis (Update): Draft guidelines]. London. National Institute for Health and Care Excellence.  Back to cited text no. 2
3.Rahme E, Barkun A, Nedjar H, Gaugris S, Watson D. Hospitalizations for upper and lower GI events associated with traditional NSAIDs and acetaminophen among the elderly in Quebec, Canada. Am J Gastroenterol 2008;103:872-82.  Back to cited text no. 3
4.National Institute for Health and Care Excellence. [Osteoarthritis (Update): Consultation comments table]. London. National Institute for Health and Care Excellence(2013).  Back to cited text no. 4
5.National Institute for Health and Care Excellence. [CG177 Osteoarthritis: NICE guideline]. London. National Institute for Health and Care Excellence (2013).  Back to cited text no. 5


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