A Cochrane review included 15 studies with 759 participants. Of eight trials that studied topical NSAIDs (301 participants), five compared topical NSAIDs with placebo, one compared manipulative therapy and topical NSAIDs with manipulative therapy alone, one compared leech therapy with topical NSAIDs and one compared two different topical NSAIDs. Of seven trials that investigated oral NSAIDs (437 participants), two compared oral NSAIDs with placebo, one compared oral NSAIDs and bandaging with bandaging alone, three compared oral NSAIDs with glucocorticoid injection, one compared oral NSAIDs with a vasodilator and two compared two different oral NSAIDs. No trials directly compared topical NSAIDs with oral NSAIDs. The median follow-up was 2 weeks (range 1 week to 1 year).
Topical NSAIDs were significantly more effective than placebo with respect to pain in the short term (MD -1.64, 95% CI -2.42 to -0.86, three trials 153 participants) and number needed to treat to benefit (7 (95% CI 3 to 21) on a 0 to 10 scale). One trial (85 participants) indicated that significantly more participants reported fair, good or excellent effectiveness with topical NSAIDs versus placebo at 28 days (14 days of therapy) (RR 1.49, 95% CI 1.04 to 2.14). No participants withdrew as the result of adverse events, but some studies reported mild adverse effects such as rash in 2.5% of those exposed to topical NSAIDs compared with 1.3% of those exposed to placebo.
One trial of oral NSAIDS found significantly greater improvement in pain compared with placebo, and the other trial found no between-group differences; neither trial found differences in function.
One trial regarding the comparative effects of oral NSAIDs and glucocorticoid injection reported a significant improvement in pain with glucocorticoid injection, and another found no between-group differences; treatment success was similar between groups (RR of fair, good or excellent effectiveness 0.74; 95% CI 0.43 to 1.26). Transient pain may occur following injection.
A subsequent RCT (n=158) compared diclofenac epolamine (2-hydroxyethyl-pyrrolidine) with placebo (DHEP) in patients with shoulder periarthritis or lateral epicondylitis. Patients were randomized to a 10-day treatment with DHEP lecithin gel or placebo (5 g t.i.d. applied on the painful area). The efficacy criteria were pain measured by visual analog scale (VAS) while performing a specific standardized movement, intake of rescue medication (paracetamol), and the disabilities of the arm, shoulder and hand (DASH) questionnaire. VAS scores indicated a consistently higher analgesic activity of DHEP lecithin gel. At day 3, pain was reduced by -20.1 +/- 20.2 and -9.9 +/- 12.7 mm in the DHEP lecithin gel- and placebo-treated patients, respectively (p < 0.001); at day 6 of treatment, DHEP lecithin gel induced a pain reduction of -33.2 +/- 26.1 mm, while the reduction achieved with placebo was only -21.2 +/- 18.8 mm (p < 0.001). The mean changes in DASH questionnaire indicated that DHEP lecithin gel was more effective than placebo in improving patient well-being and reducing difficulties in performing the activities most severely impaired by rheumatism, while no difference was observed between the two treatments in consumption of rescue medication.Comment: The quality of evidence is downgraded by limitations in study quality.
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