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Approach to managing musculoskeletal pain

Acetaminophen, cyclooxygenase-2 inhibitors, or traditional NSAIDs?

Denis Choquette, MD FRCPC
Staff Rheumatologist at the Hôpital Notre-Dame du CHUM in Montreal, Que

Brian N. Craig, MD
Department of Family Medicine at the Atlantic Health Sciences Corporation in Saint John, NB

Carlo De Angelis, PharmD
Clinical Pharmacy Coordinator—Oncology at Sunnybrook and Women’s Health Sciences Centre in Toronto, Ont

Flavio Habal, MD FRCPC PhD
Division of Gastroenterology at Toronto General Hospital

Gordon Fulthorpe, MD
Wentworth Limeridge Medical Centre in Hamilton

John I. Stewart, MD
Rural Health Services Program in Port Perry, Ont

Alexander G.G. Turpie, MD FRCP FACP FACC
Hamilton Health Science Corporation

Paul Davis, MB ChB FRCPC FRCPUK
Associate Dean of Continuing Medical Education at the University of Alberta in Edmonton

Correspondence to: Dr Richard H. Hunt, McMaster University Medical Centre, 1200 Main St W, Room 4W8A, Hamilton, ON L8N 3Z5; telephone 905 521–2100, extension 73219; fax 905 521–5072; e-mailhuntr{at}mcmaster.ca

OBJECTIVE To provide family physicians and pharmacists with practical, evidence- and expertise-based guidance on choosing the safest approach to using analgesics to manage patients with musculoskeletal pain.

SOURCES OF INFORMATION Health care providers from family practice, rheumatology, gastroenterology, hepatology, internal medicine, and pharmacy participated in an educational needs assessment regarding the management of pain and the safety of commonly used analgesics. Feedback from one-on-one interviews was compiled and distributed to participants who selected key topics. Topics chosen formed the basis for the discussions of this multidisciplinary panel that reviewed data on the safety of analgesics, particularly in regard to comorbidity and concurrent use with other therapies.

MAIN MESSAGE Treatment should begin with an effective analgesic with the best safety profile at the lowest dose and escalate to higher doses and different analgesics as required. Acetaminophen is a safe medication that should be considered first-line therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with potential adverse gastrointestinal, renal, hepatic, and cardiovascular effects. Physicians should not prescribe NSAIDs before taking a careful history and doing a physical examination so they have the information they need to weigh the risks (adverse effects and potential drug interactions) and benefits for individual patients.

CONCLUSION Taking a complete and accurate history and doing a physical examination are essential for choosing the safest analgesic for a particular patient.