Cochrane for Clinicians

Putting Evidence into Practice

Topical NSAIDs for Chronic Musculoskeletal Pain in Adults


Am Fam Physician. 2017 Nov 1;96(9):573-574.

Author disclosure: No relevant financial affiliations.

Clinical Question

Are topical nonsteroidal anti-inflammatory drugs (NSAIDs) more effective than oral NSAIDs or placebo for chronic musculo-skeletal pain associated with osteoarthritis in adults?

Evidence-Based Answer

Topical diclofenac and ketoprofen are slightly more effective than placebo for relieving chronic pain associated with osteoarthritis in adults. Evidence is lacking to determine the effectiveness of topical NSAIDs compared with oral NSAIDs.1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Osteoarthritis is one of the most common presentations in outpatient primary care practices, with the knee being the joint most often involved.2 Topical NSAIDs are used to treat chronic musculoskeletal pain because they are thought to be as effective as and have fewer adverse effects than oral NSAIDs. In this updated Cochrane review, the authors sought to determine the effectiveness of topical NSAIDs vs. placebo and oral NSAIDs, as well as compare adverse effect profiles.1

This Cochrane review included 39 studies with a total of 10,631 patients who had knee osteoarthritis.1 All studies were considered to have at least moderate methodologic quality and small to moderate risk of bias. The primary outcome of the review was clinical success, defined by any of the following: (1) reduction of pain by at least 50%, (2) a very good or excellent global assessment rating of treatment, or (3) no pain or slight pain with movement of the joint. Secondary outcomes included adverse effects or withdrawals from treatment. No reports addressed topical NSAID use for other joints or for soft tissue pain. All studies included dosing of topical NSAIDs at least once daily, but dosages varied or were not always recorded.

Of the 39 studies, 33 compared a topical NSAID with placebo. Of these 33 studies, only those with topical ketoprofen and diclofenac had enough participants to allow for data pooling. Clinical success with diclofenac was

Author disclosure: No relevant financial affiliations.


show all references

1. Derry S, Conaghan P, Da Silva JA, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2016;(4):CD007400....

2. National Ambulatory Medical Care Survey: 2012 State and National Summary Tables. Accessed January 7, 2017.

3. Altman RD. New guidelines for topical NSAIDs in the osteoarthritis treatment paradigm. Curr Med Res Opin. 2010;26(12):2871–2876.

4. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee. Accessed December 31, 2016.

5. National Institute for Health and Care Excellence. Osteoarthritis: care and management. Clinical guideline 177. February 12, 2014. Accessed November 20, 2016.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at



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