Topical nonsteroidal anti-inflammatory drugs
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* Chirag Bhat
* Hans Rosenberg
* Daniel James

## Topical nonsteroidal anti-inflammatory drugs (NSAIDs) provide local analgesia and anti-inflammatory effects with minimal systemic uptake

Nonsteroidal anti-inflammatory drugs inhibit the cyclooxygenase enzyme, reducing inflammation and pain. Compared with oral formulations, topical NSAIDs work locally, with systemic uptake limited to around 5%.1 High-quality evidence supports the analgesic role of several topical NSAIDs, including diclofenac and ketoprofen.1 Salicylate-containing rubefacients are excluded from this discussion given their distinct mechanism of action.

## Topical NSAIDs are effective for specific painful conditions

Systematic reviews of placebo-controlled randomized controlled trials confirm the efficacy of several topical agents in treating pain from soft-tissue injuries and chronic osteoarthritis.1 For acute sprains and strains, topical diclofenac (number needed to treat [NNT] 2) and ketoprofen (NNT 3) improved pain by 50% from baseline within 1 week. For chronic hand and knee osteoarthritis, topical diclofenac (NNT 5) and ketoprofen (NNT 7) improved pain by 50% within 6 weeks.1

## Topical NSAIDs provide comparable pain relief to oral NSAIDs in patients with specific painful conditions

Meta-analyses have shown that topical NSAIDs provided similar pain relief to oral NSAIDs for patients with chronic osteoarthritis and for patients with acute musculoskeletal pain.1,2

## Topical NSAIDs are safer than oral NSAIDS

Substituting topical NSAIDs for oral NSAIDs reduces the incidence of severe gastrointestinal adverse events, with 1 study showing a decrease from 26% to 17%.2,3 Common adverse events from topical agents are mild and include local skin reactions (e.g., dry skin) and pruritus (number needed to harm 7).3

## Topical NSAIDs are recommended as first-line treatments over oral NSAIDs in some guidelines

Topical NSAIDs are indicated for management of musculoskeletal pain and pain from chronic osteoarthritis.4,5 Although use of NSAIDs has no recommended time limit, providers should evaluate their effectiveness after 6–12 weeks. No recommendations are available for the use of topical NSAIDs in patients with typical contraindications to NSAIDs (e.g., heart failure, anticoagulant use, renal failure).

## Footnotes

*   **Competing interests:** Hans Rosenberg is a medicolegal expert for the Canadian Medical Protective Association and sits on the editorial board of the *Canadian Journal of Emergency Medicine*. No other competing interests were declared.

*   This article has been peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

## References

1.  Derry S, Wiffen PJ, Kalso EA, et al. Topical analgesics for acute and chronic pain in adults — an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017 12;(5):CD008609.
    
    

2.  Zeng C, Doherty M, Persson MSM, et al. Comparative efficacy and safety of acetaminophen, topical and oral non-steroidal anti-inflammatory drugs for knee osteoarthritis: evidence from a network meta-analysis of randomized controlled trials and real-world data. Osteoarthritis Cartilage 2021;29:1242–51.
    
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3.  Kim M, Laumbach S, Amico J. Are topical NSAIDs safer than oral NSAIDs when treating musculoskeletal pain? Evid Based Pract 2021;24:43.
    
    

4.  Qaseem A, McLean RM, O’Gurek D, et al. Nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults: a clinical guideline from the American College of Physicians and American Academy Of Family Physicians. Ann Intern Med 2020;173:739–48.
    
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5.  Osteoarthritis in over 16s: diagnosis and management [NICE guideline]. Paris (FR): National Institute for Health and Care Excellence; 2022. Available: [www.nice.org.uk/guidance/ng226](http://www.nice.org.uk/guidance/ng226)