Wegman Anke, van der Windt Daniëlle, van Tulder Maurits, Stalman Wim, de Vries Theo
Department of General Practice, Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands.
J Rheumatol. 2004 Feb;31(2):344-54.
The interpretation of available evidence on the relative efficacy of nonsteroidal antiinflammatory drugs (NSAID) and acetaminophen in osteoarthritis (OA) has recently been debated. This systematic review summarizes the available evidence on the efficacy of NSAID compared to acetaminophen, and compares the quality and content of clinical guidelines regarding the pharmacological treatment of OA.
Published reports of randomized controlled trials (RCT) and clinical guidelines were identified by a systematic search of bibliographic databases and relevant websites. The quality of RCT was assessed by 2 reviewers independently using a standardized checklist. Data from these RCT were used to calculate pooled differences between groups for pain and disability. The methodology of identified guidelines was appraised using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument.
The search strategy resulted in the identification of 5 RCT. Statistical pooling of data from 3 trials with adequate methods and sufficient data presentation resulted in a pooled standardized mean difference for general pain of 0.33 (95% CI 0.15 to 0.51), indicating a small effect in favor of NSAID. Pooled estimates for other outcome measures were smaller. Three of the 9 identified guidelines satisfied more AGREE criteria than others, particularly regarding rigor of development. Stakeholder involvement, applicability, and editorial independence were poorly described in most guidelines. The content of recommendations regarding the use of NSAID or acetaminophen was fairly consistent.
Acetaminophen is often effective in OA and is associated with fewer adverse reactions than NSAID. Available evidence supports the recommendations of recent guidelines to use acetaminophen as initial therapy for OA in addition to nonpharmacological interventions. Further research is needed to establish the efficacy of NSAID or acetaminophen in relevant subgroups of patients. We agree with guidelines that it is important that treatment is tailored to individual patients taking into account the severity of symptoms, previous use of acetaminophen, and the patient's knowledge, expectations, and preferences.
非甾体抗炎药（NSAID）与对乙酰氨基酚在骨关节炎（OA）中的相对疗效的现有证据解读近来备受争议。本系统评价总结了NSAID与对乙酰氨基酚疗效的现有证据，并比较了关于OA药物治疗的临床指南的质量和内容。
通过系统检索文献数据库和相关网站，识别已发表的随机对照试验（RCT）报告和临床指南。由2名审阅者独立使用标准化清单评估RCT的质量。这些RCT的数据用于计算组间疼痛和残疾的合并差异。使用AGREE（研究与评价指南评估）工具评估所识别指南的方法。
检索策略共识别出5项RCT。对3项方法适当且数据呈现充分的试验的数据进行统计合并，得出一般疼痛的合并标准化均差为0.33（95%CI 0.15至0.51），表明NSAID有小的优势。其他结局指标的合并估计值较小。9项识别出的指南中有3项比其他指南更符合AGREE标准，尤其是在制定的严谨性方面。大多数指南对利益相关者的参与、适用性和编辑独立性描述不足。关于使用NSAID或对乙酰氨基酚的推荐内容相当一致。
对乙酰氨基酚在OA中通常有效，且与NSAID相比不良反应较少。现有证据支持近期指南的推荐，即除了非药物干预外，将对乙酰氨基酚作为OA的初始治疗。需要进一步研究以确定NSAID或对乙酰氨基酚在相关患者亚组中的疗效。我们认同指南观点，即考虑症状严重程度、既往对乙酰氨基酚使用情况以及患者的知识、期望和偏好，为个体患者量身定制治疗非常重要。
