All Analgesics Are Better Than Placebo in Patients with Knee or Hip DJD


Am Fam Physician. 2016 Oct 15;94(8):664-665.

Clinical Question

Which analgesics are most effective in treating patients with degenerative joint disease (DJD) of the hip or knee?

Bottom Line

In patients with hip or knee DJD, all analgesics are more effective than placebo in relieving pain and improving function. Although paracetamol (acetaminophen) is the least effective of all the drugs studied, it still may be the first treatment for these patients because of its safety profile. Move on to other agents, if necessary, according to the patient's response. (Level of Evidence = 1a −)


These authors searched the Cochrane Central Register of Controlled Trials to identify randomized trials comparing nonsteroidal anti-inflammatory drugs, paracetamol, and placebo in patients with DJD of the hips or knees. The studies had to have at least 100 patients in each group. Two researchers independently evaluated each study for inclusion and used discussion to resolve disagreements. The team assessed each study's methodologic quality and extracted data related to pain and function. They ultimately included 74 trials with nearly 59,000 patients, seven different drugs, and 23 different permutations. Across the trials, the mean age of patients ranged from 58 to 71 years, most patients were women (49% to 90%), and most studies were of short duration (median follow-up of 12 weeks; range = 1 to 52 weeks). None of the studies were at high risk of bias.

All analgesics, regardless of dose, were more effective than placebo in relieving pain. However, several agents were more likely to provide clinically important relief (diclofenac, 150 mg per day; etoricoxib, 30, 60, and 90 mg per day; and rofecoxib, 25 and 50 mg per day). Paracetamol was the least likely to provide meaningful pain relief. Although patients generally functioned better while taking medication, the data on improved function were not particularly robust and no treatment stood out as better than the rest. The authors do not directly assess the harms of treatment. Finally, rofecoxib has been withdrawn from the worldwide market, and etoricoxib is not available in the United States because of U.S. Food and Drug Administration demands for further safety information.

Study design: Meta-analysis (randomized controlled trial)

Funding source: Foundation

Setting: Various (meta-analysis)

Reference: da Costa BR, Reichenbach S, Keller N, et al. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis. Lancet. 2016;387(10033):2093–2105.

POEMs (patient-oriented evidence that matters) are provided by EssentialEvidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

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This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.



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