Conclusion

• Paracetamol is well tolerated and safe, except in overdose.

• Paracetamol is a first line agent in mild-to-moderate pain of OA.

• Combinations of paracetamol with other agents offer little real benefit and have increased risk of side effects. They may be of benefit in short-term use.

• There is good evidence for NSAIDs benefit in acute and chronic inflammatory pain but minimal evidence in neuropathic pain.

• NSAIDs are widely used by prescription and as over the counter medicines. The side effects of NSAIDs are potentially life-threatening but this must be examined in the context of the enormous scale of usage of this class of drugs.

• The newer COX-2 antagonists have potential benefits but should be used with caution because of the risks in patients with concurrent cardiac disease.

• Clinically, agents with lower risk should be tried first and at the lowest recommended dose before titration, having first assessed the efficacy of paracetamol. Trialing several agents and drug rotation may be beneficial with some patients.

• Elderly patients are at greater risk for side effects than the young.

• Further high quality systematic review or new research has to be carried out to evaluate:

- relative efficacies between agents;

- long-term effects in terms of risk and benefit;

- the effects of common combinations in chronic pain;

- what role, if any, there is in neuropathic pain for these agents.

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