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Musculoskeletal pain is a common, chronic problem, which can compromise the lives of sufferers both physically and emotionally. Many sufferers are able to manage their pain and carry on with their lives, but only 17 per cent of households in the UK are using topical pain relief.1
Chronic musculoskeletal conditions require long-term treatment but some commonly used oral painkillers should not be taken for prolonged periods. With questions raised over the use of aspirin, ibuprofen and paracetamol in back pain and other musculoskeletal problems, especially long-term, and diclofenac no longer available OTC in oral form2-5, should topicals now be considered as first-line for musculoskeletal pain in suitable patients?
Oral pain relief medication is absorbed into the bloodstream through the digestive tract and enters the liver, where it is metabolised. From there, it passes into other organs before finally reaching the musculoskeletal system.
In contrast, topical analgesics are applied directly at the point of pain, concentrating their action on the area where pain is felt. Drug-free topicals do not pass through the internal organs, which helps avoid unwanted side-effects such as gastrointestinal problems. This is particularly relevant in ongoing conditions, such as arthritis or chronic back pain, where prolonged treatment is required.
Topical analgesics may also be a useful alternative option in patients who are already taking other oral medications or where compliance is an issue.
NICE recognises the role topicals can play in relieving pain. Guidelines on treating osteoarthritis, published in February 20146, built on the advice given in the 2008 NICE guidelines. While still recommending paracetamol as an oral option, the newer guidelines also advised:
• Considering topical NSAIDs for pain relief in addition to core treatments for people with knee or hand osteoarthritis
• Considering topical NSAIDs and/or paracetamol ahead of oral NSAIDs, COX-2 inhibitors or opioids.
The OTC topicals fixture offers a wide range of options, with hot, cold and NSAID products available, and includes both licensed OTC medicines and drug-free options. But before making any recommendation it is essential to understand the type of pain the customer is suffering from.
OTC topical NSAIDs are available as creams, gels or patches, and may contain active ingredients including ibuprofen, diclofenac or ketoprofen. They can be used to help relieve inflammatory back, muscle and joint pain – including rheumatic pain, sprains and strains – and some may also be recommended for non-serious arthritic pain.
There is considerable evidence to show that topical NSAIDs are effective and may be associated with fewer adverse effects than orals. For example, a Cochrane Review published in June 2015 (‘Topical non-steroidal anti-inflammatory drugs for acute musculoskeletal pain in adults’) updated a previous review from 2010.7 Looking at a total of 61 studies, the authors concluded that, “topical NSAIDs provided good levels of pain relief in acute conditions such as sprains, strains and overuse injuries, probably similar to that provided by oral NSAIDs”.
They noted that adverse events were minimal and said that, “the present review supports the previous review in concluding that topical NSAIDs are effective in providing pain relief, and goes further to demonstrate that certain formulations, mainly gel formulations of diclofenac, ibuprofen and ketoprofen, provide the best results”.
Another paper published in 2000 compared the use of oral and topical NSAIDs in rheumatic diseases.8 The authors concluded that:
• Topical administration of NSAIDs offers the advantage of local, enhanced drug delivery to affected tissues with a reduced incidence of systemic adverse effects, such as peptic ulcer disease and GI haemorrhage
• Compared with oral administration, topical application leads to relatively high NSAID concentrations in the dermis. Concentrations achieved in the muscle tissue below the site of application are variable, but are at least equivalent to that obtained with oral administration
• Topically applied NSAIDs have a superior safety profile to oral formulations
• Available clinical studies suggest, but do not document, equivalent efficacy of topical and oral NSAIDs in rheumatic diseases.
The heat sector offers a range of medicines and drug-free pain relief available as rubs, creams, lotions, sprays and patches.
Heat products can be recommended to help relieve muscular aches, pains and stiffness such as nagging back pain, painful, stiff and aching muscles or tight knotted muscles. Some products may also be recommended for use before exercise. If they are being used after an injury (e.g. a sprain or strain), heat therapy should only be started once inflammation has decreased – usually 72 hours after the injury.
The products are designed to create rubefacient and counter-irritation sensations on the skin. When heat is applied topically, it activates receptors in the skin that transmit ‘heat’ signals to the brain via the spinal cord gateway. This helps to crowd out pain signals transmitted along the same route, so fewer reach the brain and less pain is felt. Heat also increases the temperature of the skin and underlying tissue, increasing blood flow, and transporting oxygen and nutrients to aid healing and help restore movement.
Ingredients in topical preparations include:
Salicylates: These are absorbed into the skin to a depth of about 3-4mm and produce local dilation of blood vessels, creating a sensation of warmth. Their counter-irritant mechanism helps mask the perception of pain by crowding out pain nerve signals and also by being converted to salicylic acid in skin tissue, where they have an anti-inflammatory action.
Menthol: produces a cooling sensation on the skin at concentrations of around 1 per cent. Higher concentrations of around 2 per cent produce a warming feeling. Both sensations can help curb pain by crowding out pain signals on the nerve pathway.
Nicotinates: produce vasodilation and increased skin temperature.
Cold products available over the counter include sprays, gels, patches and wraps. They can be recommended to help relieve sharp, shooting muscle, joint and foot pain, sprains and strains. Some drug-free options can also be recommended to relieve muscular back pain in pregnancy. The products offer a convenient alternative to ice packs.
Cold treatment uses low temperatures to relieve pain when treating an injury such as a sprain or strain. Cold should be applied as soon as possible after an injury or trauma when tissues are stretched and blood vessels torn or damaged, with swelling and inflammation. This treatment should be continued for 72 hours after the injury.
As with heat, when cold is applied topically, it activates receptors in the skin, sending cold messages along the spinal cord to the brain, crowding out pain signals and reducing the feeling of pain. When applied to an injured area, it helps constrict the blood vessels in the soft tissue, which can help reduce tissue bleeding, inflammation and swelling.
In summary, OTC topical analgesics offer proven, effective pain relief and are available in a comprehensive range of options – hot, cold and topical NSAIDs, OTC medicines and drug-free products, in a variety of formats from rubs, gels, lotions and creams to sprays and patches.
So, when a patient asks for something to help relieve their back pain, joint pain, sciatica or other musculoskeletal problem, maybe pharmacists and their teams should be actively considering which topical analgesic would be most suitable to bring needed relief.
Before making any recommendation it is essential to understand the type of pain the customer is suffering from
1. Consumer research carried out on behalf of The Mentholatum Company
2. Huang ES, Strate LL, Ho WW, Lee SS, Chan AT. Long-term use of aspirin and the risk of gastrointestinal bleeding. Am J Med. 2011 May; 124(5):426-33. doi: 10.1016/j.amjmed.2010.12.022BMJ 2016;354:i4857
3. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 2014;384:1586–96. doi:10.1016/S0140-6736(14)60805-9
4. Hazlewood G, van der Heijde DM, Bombardier C. Paracetamol for the management of pain in inflammatory arthritis: a systematic literature review. J Rheumatol Suppl 2012; 90:11-16. doi:10.3899/jrheum.120336
5. van Walsem A, Pandhi S, Nixon RM et al. Relative benefit-risk comparing diclofenac to other traditional non-steroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors in patients with osteoarthritis or rheumatoid arthritis: a network meta-analysis. Arthritis Res Ther 2015;17:66. doi:10.1186/s13075-015-0554-0
6. nice.org.uk/guidance/cg177/chapter/1-Recommendations# pharmacological-management
7. Derry S, Moore R, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database of Systematic Reviews 2015, Issue 6. art. no: CD007402. DOI: 10.1002/14651858.CD007402.pub3
8. Oral versus topical NSAIDs in rheumatic diseases: a comparison. Heyneman CA1, Lawless-Liday C, Wall GC. Drugs. 2000 Sep; 60(3):555-74
9. Newton JN, Briggs ADM, Murray CJL, Dicker D, Foreman KJ, Wang H et al. Changes in health in England, The Lancet 2015