The 2022 Chinese Multidisciplinary Guidelines for the Rational Use of Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for Musculoskeletal Pain, published in J. Clin. Med. (2023; 12: 1544), provides 11 evidence-based recommendations and 9 expert consensuses, focusing on indications, administration, drug selection, special populations, and safety monitoring to standardize topical NSAID use for acute and chronic musculoskeletal painPMC. Below is a structured English summary and clinical application framework.
Basic Information & Development Methodology
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Item |
Details |
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Title |
Multidisciplinary Guidelines for the Rational Use of Topical Non-Steroidal Anti-Inflammatory Drugs for Musculoskeletal Pain (2022) |
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Publisher |
Hospital Pharmacy Professional Committee of Chinese Pharmaceutical Association |
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Publication |
J. Clin. Med. 2023, 12, 1544; DOI: 10.3390/jcm12041544 (Open Access) |
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Target Population |
Patients with acute/chronic musculoskeletal pain (e.g., osteoarthritis, soft tissue injury, myofascial pain) |
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Methodology |
WHO handbook, GRADE, Delphi method, systematic review, multidisciplinary panel (clinicians, pharmacists, nurses)PMC |
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Core Goal |
Address unmet needs in drug selection, dosing, interactions, and special population use |
Core Recommendations & Expert Consensuses (11+9)
1. Indications & First-Line Position (Recommendations 1–3)
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Recommendation 1 (1B): Topical NSAIDs are recommended for acute musculoskeletal pain (e.g., sprains, strains, tendinitis) as first-line therapy, with comparable efficacy to oral NSAIDs and lower systemic adverse events (AEs).
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Recommendation 2 (1B): Topical NSAIDs are conditionally recommended for chronic musculoskeletal pain (e.g., knee osteoarthritis) to reduce pain and improve function; combine with oral paracetamol for refractory cases.
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Recommendation 3 (2C): Prefer topical over oral NSAIDs in patients with high risks of GI/CV/renal AEs, given lower systemic exposure.
2. Administration & Dosing (Recommendations 4–6)
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Recommendation 4 (2C): Apply directly to the painful site; massage gently to enhance absorption (non-patch formulations).
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Recommendation 5 (2C): Standardize dosage by preparation type:
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Gels/creams: 2–4 g per application, 3–4 times daily; max 16 g/day for diclofenac.
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Patches: 1 patch/day, apply to intact skin for 12–24 hours (avoid prolonged use).
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Recommendation 6 (2C): Treat for 2–4 weeks initially; extend to 8 weeks if effective and well-tolerated.
3. Drug Selection (Expert Consensus 1–3)
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No evidence supports superiority of one topical NSAID over others; select based on patient factors (e.g., skin sensitivity, adherence, formulation preference).
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Prefer low-molecular-weight (<500 Da) NSAIDs (e.g., diclofenac, ketoprofen) for better transdermal penetration.
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Avoid combinations of multiple topical NSAIDs to prevent local irritation.
4. Combination Therapy (Expert Consensus 4–6)
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Combine with oral paracetamol for moderate-to-severe pain as short-term rescue therapy.
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Avoid routine combination with oral NSAIDs to reduce systemic AE risks.
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Monitor INR in patients on warfarin + topical NSAIDs; no evidence of increased bleeding risk with ACEI/ARB/statins.
5. Special Populations (Recommendations 7–11 & Consensuses 7–9)
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Population |
Key Guidance |
Evidence/Level |
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Pregnancy |
Avoid in third trimester; short-term use in second trimester may be safe (very low evidence); no data for first trimester (Consensus 12) |
Expert Consensus |
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Lactation |
Use cautiously with informed consent; monitor infant for skin/mucosal reactions (Consensus 13) |
Expert Consensus |
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Children (≥6 years) |
Recommended for pain; monitor local AEs (e.g., rash) (Recommendation 16, 2C) |
2C |
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Elderly |
Recommended; lower systemic AEs vs oral NSAIDs; monitor local skin reactions (Recommendation 17, 2C) |
2C |
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Hepatic/Renal Impairment |
Use cautiously; monitor LFTs/renal function (Consensuses 14–15) |
Expert Consensus |
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CV Disease |
No direct evidence of increased risk; safer than oral NSAIDs (Consensus 18) |
Expert Consensus |
6. Safety Monitoring (Consensuses 7–9)
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Local AEs: Erythema, pruritus, rash (discontinue if severe).
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Systemic AEs: Rare; monitor for edema, hypertension, GI upset in long-term use.
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Contraindications: Hypersensitivity to NSAIDs, active skin lesions at application site, third-trimester pregnancy.
Clinical Application Flowchart
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Indication Check: Confirm localized musculoskeletal pain (no widespread/systemic inflammation).
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Risk Stratification: Assess GI/CV/renal risks; prioritize topical NSAIDs in high-risk patients.
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Product Selection:
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Gels/creams: Flexible for large areas; suitable for acute pain.
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Patches: Controlled release; better for chronic localized pain (e.g., knee OA).
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Dosing: Follow standard dosage; avoid over-application.
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Monitoring:
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Local: Check skin weekly for irritation.
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Systemic: LFTs/renal function at baseline and 4–8 weeks (long-term use).
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Response Evaluation: Reassess pain intensity at 2 weeks; adjust therapy if no improvement.
Key Evidence Highlights
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Efficacy: Topical NSAIDs achieve therapeutic concentrations at the site of action with minimal systemic absorption.
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Safety: Lower GI AEs vs oral NSAIDs (RR 0.66, 95% CI 0.56–0.77) and comparable efficacy (RR 1.04, 95% CI 0.97–1.12).
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Cost-Effectiveness: Reduces hospitalization costs from systemic AEs; improves adherence vs oral formulationsPMC.
Implementation Tips
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Informed Consent: Document discussion of benefits, risks, and alternatives.
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Formulary Compliance: Select products with local formulary approval and evidence support.
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Patient Education: Instruct proper application (clean/dry skin, avoid contact with eyes/mucous membranes).