A Guide For Choosing An Appropriate NSAID

Due to the increasing rise in drug abuse from opioids and recent safety warnings regarding nonsteroidal antiinflammatory drugs, or NSAIDs, practitioners are beginning to show more interest in topical agents.

There are several factors that should be considered prior to using a topical agent. Some factors include pain type, duration, skin sensitivity, and allergies.

One major advantage to topical pain relief is the local delivery system as well as a significant decrease in systemic side effects.

The chart below offers a guide on how to recommend topical pain relief to different patient populations. Always remember to counsel patients on proper use and review clinical pearls.

Topical Agent

Pros

Cons

Clinical Pearls

Diclofenac/ compounds (ketoprofen, ibuprofen, piroxicam, etc) ^1,2,3,4,5

Lower risk of systemic effects compared to PO NSAIDS (in particular GI effects)

Evidence that these are equivalent to PO forms for treating osteoarthritis and acute musculoskeletal pain

Increased risk of dermatologic effects

More expensive than PO NSAIDs

Useful for localized pain or if there is a concern for systemic effects

Pennasaid and Voltaren are FDA approved for osteoarthritis

Flector is approved for acute sprains

Do not combine topicals and PO NSAIDs

DMSO used in diclofenac solution improves absorption

Lidocaine patches ^7,8

Potentially beneficial for neuropathic pain

Very low blood levels equates to few systemic effects

Limited evidence in efficacy for neuropathic pain

Skin irritant in patients w/ sensitive skin

Potential toxicity/death if not properly counseled

1st line treatment in patients who cannot tolerate PO meds

1st line treatment in patients who have concerning systemic reactions

5% patch is FDA approved and is RX only

4% patch is OTC w/ variable dosing

Capsaicin ^{2, 6}

Potentially useful in osteoarthritis and rheumatoid arthritis

Useful in postherpetic neuralgia and HIV neuropathy

Rare systemic effects

Local skin reactions/irritation can occur

Requires multiple applications per day

Counsel patients it can take up to 2-4 weeks to take full effect

Start with a low dose and titrate up due to tolerability

counsel patients to wash their hands after applying. Avoid using a heating pad concurrently

Menthol, camphor, Bengay, Icy Hot, etc ^2,9

Beneficial for short term mild pain

Available OTC

Not for chronic or acute conditions

Topical salicylates are not effective for osteoarthritis

Counsel patients to wash their hands after applying

Other agents- TENS units/ kinesology tape ^10,11

TENS units and tape are considered safe

Limited quality evidence is available for tape

Occasional reports of local irritation or allergic reactions to tape

Inconclusive and conflicting evidence for TENS units

Counsel patients not to use either product on broken skin

References

1. Derry S, Moore RA, Gaskell H, et al. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015;(6):CD007402. Accessed December 12, 2016.

2. Chou R, McDonagh MS, Nakamoto E, Griffin J. Analgesics for osteoarthritis: an update of the 2006 comparative effectiveness review. October 2011. http://www.effectivehealthcare.ahrq.gov/ehc/products /180/795/Analgesics-Update_CER. Accessed December 14, 2016.

3. Hickman D, Chou R, King V, et al. Choosing nonopioid analgesics for osteoarthritis. Clinician’s guide. Agency for Healthcare Research and Quality. 2009. http://www.effectivehealthcare.ahrq.gov/ehc/products /2/5/Osteoarthritis_Clinician_Guide.pdf. Accessed December 12, 2016.

4. Product information for Pennsaid. Horizon Pharma. Deerfield, IL 60015. May 2016. Accessed December 12, 2016.

5. Product information for Voltaren. Novartis. Parsippany, NJ 07054. July 2009. Accessed December 12, 2016.

6. Moulin D, Boulanger A, Clark AJ, et al. Pharmacological management of chronic neuropathic pain: revised consensus statement by the Canadian Pain Society. Pain Res Manag. 2014;19:328-35.

7. De Leon-Casasola OA, Mayoral V. The topical 5% lidocaine medicated plaster in localized neuropathic pain: a reappraisal of the clinical evidence. J Pain Res. 2016;9:67-79.

8. FDA. FDA alerts public about danger of skin numbing products: serious and life-threatening risks associated with improper use. January 2009. http://www.fda.gov/NewsEvents/Newsroom/PressAn nouncements/ucm109068.htm. Accessed December 14, 2016.

9. Derry S, Matthews PR, Wiffen PJ, Moore RA. Salicylate-containing rubefacients for acute and chronic musculoskeletal pain in adults. Cochrane Database Syst Rev 2014;(11):CD007403. Accessed December 20, 2016.

10. Walsh DM, Howe TE, Johnson MI, Sluka KA. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database Syst Rev 2009;(2):CD006142. Accessed December 20, 2016.

11. Mikolajewska E. Side effects of kinesiotaping — own observations. J Health Sci 2011;1:93-99.