SLR - February 2019 - Bridget Metzo

Acetaminophen or Nonsteroidal Anti-Inflammatory drugs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, Randomized, Clinical Trial

Reference:  Ridderikhof ML, Lirk P, Goddijin H, Vandewalla E, Schinkel E, Van Dieren S, Kemper EM, Hollmann MW, Goslings JC. Acetaminophen or Nonsteroidal Anti-Inflammatory Drugs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, Randomized, Clinical Trial. Annals of Emergency Medicine. 2018 Mar; 71(3): 357–368.

Scientific Literature Review

Reviewed By: Bridget Metzo, DPM
Residency Program: University Hospital, Newark, NJ

Podiatric Relevance: With the continued presence of an opioid epidemic at our hands, the search for a less addictive and less medically harmful analgesic alternative continues. The podiatric surgeon typically prescribes opioids in the immediate postoperative period; however, in the following weeks, a less addictive analgesic, such as an NSAID, is typically prescribed. NSAIDs are also the most common firstline pain reliever in minor musculoskeletal traumas but not without their potential harmful effects on the cardiovascular, renal or gastrointestinal systems. This study sought to determine if acetaminophen is as effective as diclofenac or the combination of acetaminophen and diclofenac in treating pain in adult patients with minor musculoskeletal trauma of an extremity.

Methods: A level 1, multicenter, double-blind, randomized clinical trial was performed with participation of 547 patients aged 18+ presenting with acute musculoskeletal trauma of an extremity. Each patient randomly assigned in a 1:1:1 ratio to acetaminophen 4,000 mg/day, diclofenac 150 mg/day or acetaminophen 4,000 mg/day + diclofenac 150 mg day for three consecutive days. The NRS pain score, which rates pain 0–10, was the primary outcome measurement. This measurement was assessed at baseline and at 90 minutes after medication initiation, with rest and movement. Secondary outcomes included NRS pain scores for three consecutive days, and the patients followed for a total of 30 days.

Results: The NRS pain score was reduced in all three patient groups, compared to baseline. At rest, the NRS numbers for acetaminophen were –1.23 (95 percent CI –1.50 to –0.95), diclofenac–1.20 (95 percent CI –1.44 to –0.96) and –1.18 (95 percent CI –1.41 to –0.94) in the combination group. The numbers increased with movement; acetaminophen –1.72 (95 percent CI –2.01 to –1.44), diclofenac –1.52 (95 percent CI –1.77 to –1.26) and combination –1.33 (95 percent CI –1.55 to –1.12). No statistically significant difference in NRS decreases detected. Occurrence of adverse effects was equally divided among the treatment groups, and none of the adverse events required hospitalization.

Conclusions: The use of acetaminophen alone for pain relief in acute musculoskeletal trauma of the extremity is comparable to NSAIDs and combination therapy. Therefore, when looking to add an additional analgesic to acetaminophen treatment, addition of an NSAID will not aid in pain reduction, and a class other than NSAIDs may be preferable. This study does not take into account the anti-inflammatory benefits of NSAID use for the treatment of acute musculoskeletal trauma; however, for the treatment of pain relief alone, when an NSAID is not feasible, acetaminophen is comparable.

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