Topical vs. oral NSAIDs for joint and arthritis pain

Both topicals and NSAID pills can help joint pain, but which is the winner?

There has been substantial research showing not only the strong prevalence of joint pain within the general population, but also its costs in terms of economics, mental health and overall quality of life. This research has also shown a continuing increase in patients’ interest in complementary health care, particularly chiropractic, to address pain issues.¹

Given this rising popularity, it should not be surprising if within your own practice you see a similar trend of patients seeking relief from joint pain.

While adjustments can go a long way toward relieving joint pain, your patients may also be looking for treatments they can do at home, particularly if they have an acute flare-up. Standard medical treatment would recommend the use of oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil or Motrin) or naproxen (Aleve). However, these medications can have serious side effects.

Recent research on topical NSAIDs for treating acute pain relief directly at the affected joints has been promising. However, topicals are better suited to treat localized rather than generalized pain. Let’s do a side-by-side comparison to see which type of NSAID will be best for your patients with joint pain.

Oral NSAIDs

Oral NSAIDs block the cyclooxygenase (COX) enzyme, which is responsible for pain and swelling. Because oral NSAIDs are absorbed into the bloodstream via the digestive system, the most common issues are usually those associated with the gastro-intestinal system.²

As a result, oral NSAIDs, particularly those that require a prescription, are generally only recommended for the short term. Over the long term, they can cause stomach ulcers and bleeding, damage the liver and kidneys, and also increase the risk of heart attack.²

Oral NSAIDs may be well-suited for treating acute pain following surgery or an internal injury, but are generally not as effective at treating chronic joint pain near the surface of the skin. In fact, a 2017 article in the Journal of the American Heart Association compared the risk of adverse cardiac events between oral and topical NSAIDs in a group of Taiwanese patients with rheumatoid arthritis.³ The researchers found there was less risk of a cardiac event with topical than with oral NSAIDs.

They concluded: “Our results suggested that topical nonselective NSAIDs may be a safer alternative for relieving muscle‐skeletal pain in patients with cardiovascular diseases, including those receiving aspirin concurrently.” This study is particularly notable, as patients with rheumatoid arthritis have anywhere from a 1.5- to a 2-fold greater risk of coronary artery disease than is seen in the general population.³

Topical NSAIDs

Topical NSAIDs, usually in the form of creams or gels, are applied to the surface of the skin at the localized area of the painful joint. Unlike oral NSAIDs, topicals are not absorbed systemically, but work only at the targeted area.² As a general rule, side effects from topicals are much less severe than those from oral NSAIDs, and are often limited to rashes, itching or a burning sensation at the application site.²

The literature has presented a number of small studies showing promise for topical NSAIDs in treating joint pain. More recent research has reviewed the results of these smaller studies, including a 2013 paper that examined 15 papers with more than 3,000 subjects, 2,400 of whom had osteoarthritis.⁴ The authors found that topical NSAIDs were better tolerated than oral NSAIDs, particularly for those patients with osteoarthritis.

Another paper from 2012 performed what is known as a meta-analysis to look for commonalities among the results of smaller papers.⁵ By pooling together similar results, the strength of the findings can be increased. In the case of this particular paper, topical NSAIDs and oral NSAIDs were found to provide the same levels of pain relief, but topicals had a significantly reduced incidence of gastrointestinal adverse side effects. One particular topical NSAID, diclofenac, was found to reduce musculoskeletal pain by as much as 50% over the course of eight to 12 weeks.⁵

References

1. Adams J, Peng W, Cramer H, et al. The prevalence, patterns, and predictors of chiropractic use among US adults: Results From the 2012 National Health Interview Survey. Spine. 2017 Dec 1;42(23):1810-1816.
2. Harvard Health Letters. NSAIDs: Topicals vs. pills for pain. https://www.health.harvard.edu/pain/nsaids-topicals-vs-pills-for-pain. Published January 2013. Accessed April 15, 2019.
3. Lin TC, Solomon DH, Tedeschi SK, et al. Comparative risk of cardiovascular outcomes between topical and oral nonselective NSAIDs in Taiwanese patients with rheumatoid arthritis. Journal of the American Heart Association. 2017;6(11):e006874.
4. Klinge SA, Sawyer GA. Effectiveness and safety of topical versus oral nonsteroidal anti-inflammatory drugs: A comprehensive review. The Physician and Sportsmedicine. 2013 May;41(2):64-74.
5. Derry S, Moore RA, Rabbie R. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database of Systematic Reviews. 2012;9(9):CD007400.