What are the treatment options for musculoskeletal pain not relieved by over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs)?

Treatment Options for Musculoskeletal Pain Not Relieved by OTC NSAIDs

For musculoskeletal pain not adequately controlled with over-the-counter NSAIDs, topical NSAIDs with or without menthol gel should be tried as first-line therapy before escalating to other pharmacological options.

First-Line Options After OTC NSAID Failure

Topical Treatments

• Topical NSAIDs: Strong evidence supports using prescription-strength topical NSAIDs (diclofenac, ketoprofen) as first-line therapy 1, 2

  • Diclofenac gel (Emulgel®) has shown excellent efficacy with NNT of 1.8 3
  • Ketoprofen gel has demonstrated good efficacy with NNT of 2.5 3
  • Provides effective pain relief with fewer systemic side effects than oral medications
  • Can be used with or without menthol gel for enhanced effect

• Other topical options:

  • Capsaicin cream for localized pain 1
  • Methyl salicylate or menthol as counterirritants 1

Oral Medications

• Prescription-strength oral NSAIDs: Consider if topical treatments are insufficient 1, 2

  • COX-2 inhibitors (celecoxib) or traditional NSAIDs with gastroprotection (PPI) for patients with GI risk factors
  • Use lowest effective dose for shortest duration to minimize adverse effects

• Acetaminophen: Maximum 4g/day (lower doses in elderly or those with liver disease) 1, 2

  • May be used in combination with topical treatments
  • First choice for patients with cardiovascular disease or contraindications to NSAIDs

Second-Line Options

Pharmacological Options

• Tramadol or other opioids: Consider only when other options have failed 1

  • Note: ACP and AAFP recommend against opioids for acute non-low back musculoskeletal injuries 1
  • May be appropriate for severe pain unresponsive to other treatments
  • Should be carefully titrated and monitored

• Neuropathic pain medications: For pain with neuropathic features 2

  • Gabapentin: Start at 300mg daily and titrate up to 1800-3600mg/day divided in three doses 4
  • Tricyclic antidepressants may be considered for patients with inadequate response to gabapentin

Interventional Approaches

• Intra-articular injections: For joint pain not responding to other therapies 1
  • Corticosteroid injections for acute episodes of pain, especially with inflammation and joint effusion
  • Hyaluronic acid preparations for knee osteoarthritis not adequately relieved with other therapies

Non-Pharmacological Approaches

• Physical therapy and exercise: Regular moderate exercise and physical therapy 1, 2

  • Local muscle strengthening and general aerobic fitness
  • Aquatic therapy in warm water (86°F) for painful joints

• Physical modalities:

  • Transcutaneous electrical nerve stimulation (TENS) 1, 2
  • Local heat or cold applications 1
  • Acupressure for specific pain points 1

• Supportive devices:

  • Braces, joint supports, or insoles for biomechanical joint pain or instability 1
  • Assistive devices for specific functional limitations

Special Considerations

Risk Stratification

• Cardiovascular risk: Use caution with NSAIDs, especially COX-2 inhibitors 1, 2

  • Consider acetaminophen, non-acetylated salicylates, or short-term carefully monitored opioid analgesics

• GI risk: Use COX-2 inhibitors or traditional NSAIDs with PPI protection 1

• Renal risk: Monitor renal function with NSAID use, including COX-2 inhibitors 1

• Elderly patients: Start with lower doses and monitor more frequently for adverse effects 1, 2

Common Pitfalls to Avoid

1. Prolonged NSAID use without monitoring for GI, renal, and cardiovascular adverse effects
2. Exceeding recommended acetaminophen doses, particularly in patients with liver disease
3. Early opioid prescribing before trying safer alternatives
4. Relying solely on pharmacological treatments without incorporating physical therapy and exercise
5. Failing to reassess treatment effectiveness and adjust the management plan accordingly

By following this stepped approach to musculoskeletal pain management, most patients can achieve adequate pain control with minimal risk of adverse effects.