Paracetamol versus nonsteroidal anti-inflammatory drugs for rheumatoid arthritis

In rheumatoid arthritis (RA), the joints are swollen, stiff and painful. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are often recommended to ease the pain and swelling in the joints. Paracetamol (also known as acetaminophen) is another type of medication to relieve pain in RA.

This Cochrane review found only four old and small trials of poor quality that have compared the two types of drugs. There were a total of 121 patients in the four trials. In each trial, the patients tried both types of drugs, one after the other, in different periods of the trial.

In the largest trial, of 54 patients, where each drug was tested twice, 20 patients preferred ibuprofen on both occasions, and 7 paracetamol.

In the trials, each drug was used for only 4-7 days and side effects from the drugs were poorly reported. It is therefore not clear whether NSAIDs are better than paracetamol.

Authors' conclusions: 

When considering the trade off between the benefits and harms of non-steroidal anti-inflammatory drugs and paracetamol/acetaminophen, it is not known whether one is better than the other for rheumatoid arthritis. But people with rheumatoid arthritis and the researchers in the study did prefer non-steroidal anti-inflammatory drugs more than acetaminophen/paracetamol. There is a need for a large trial, with appropriate randomisation, double-blinding, test of the success of the blinding, and with explicit methods to measure and analyse pain and adverse effects.

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Background: 

Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually preferred for simple analgesics such as paracetamol for rheumatoid arthritis. It is not clear, however, whether the trade-offs between benefits and harms of NSAIDs are preferable to those of paracetamol (paracetamol is also called acetaminophen).

Objectives: 

To compare the benefits and harms of paracetamol with NSAIDs in patients with rheumatoid arthritis.

Search strategy: 

PubMed and EMBASE databases were searched up until August 2007. Reference lists of identified articles were also searched.

Selection criteria: 

Randomised double-blind studies comparing paracetamol with an NSAID.

Data collection and analysis: 

Decisions on inclusion of trials and data extraction were performed by the two authors independently.

Main results: 

Four cross-over studies, published between 1968 and 1982, involving 121 patients, and four different NSAIDs were included. The generation of the allocation sequence and the use of methods to conceal the allocation were not described in any of the studies. The studies were double-blind but it was not clear whether the blinding was effective. Methods for collecting adverse effects were not described. The NSAIDs were preferred more often than paracetamol by the patients or the investigator. In the largest trial, 20 out of 54 patients (37%) preferred ibuprofen and 7 out of 54 (13%) paracetamol. Investigators preference (as established by joint tenderness, grip strength and joint circumference) was 17 out of 35 for diclofenac versus 5 out of 35 for paracetamol in another trial. However, because of the weaknesses in the trials, no firm conclusion can be drawn.

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