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Education And Debate

North of England evidence based guideline development project: summary guideline for non-steroidal anti-inflammatory drugs versus basic analgesia in treating the pain of degenerative arthritis

BMJ 1998; 317 doi: (Published 22 August 1998) Cite this as: BMJ 1998;317:526
  1. Martin Eccles (, professora,
  2. Nick Freemantle, senior research fellow,b,
  3. James Mason, research fellowb,
  4. for the North of England Non-Steroidal Anti-Inflammatory Drug Guideline Development Group.
  1. aCentre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4AA
  2. bCentre for Health Economics, University of York, York YO1 5DD
  1. Correspondence to: Professor Eccles
  • Accepted 6 April 1998

Other members of the guideline development and project groups are listed in the Appendix

This guideline addresses the appropriate use of non-steroidal anti-inflammatory drugs in the primary care treatment of patients with joint pain believed to be caused by degenerative arthritis. It does not consider therapies other than drug treatment. General practitioners must use their professional knowledge and judgement when applying guideline recommendations to the management of individual patients. They should note the information, contraindications, interactions, and side effects contained in the British National Formulary.1

This is a summary of the full version of the guideline.2 In this article, the statements accompanied by categories of evidence (cited as Ia, Ib, IIa, IIb, III, and IV) and recommendations classified according to their strength (A, B, C, or D) are as described previously and are summarised in the box.3

Summary points

  • Nearly 1.5 million person years of non-steroidal anti-inflammatorydrug treatment, at a cost of £150 million, were prescribed by general practitioners in 1995

  • Initial treatment for osteoarthritic pain should be paracetamol,followed by ibuprofen

  • Routine prophylaxis for gastrointestinal injury associated withnon-steroidal anti-inflammatory drugs is not appropriate in patients with osteoarthritis

  • Potential risks of side effects should be discussed with patients before starting or changing treatment

  • Paracetamol is the most cost effective drug, followed by ibuprofen

  • Topical non-steroidal anti-inflammatory agents cannot be recommended as evidence based treatment


The methods used to develop the guideline have been described previously.3Briefly, we searched the electronic databases Medline and Embase, using a combination of subject heading and free text terms aimed at locating systematic reviews, meta-analyses, randomised trials, quality of life studies, and economic studies. The search was backed up by the expert knowledge and experience of group members.

Strength of recommendation

  • A—Directly based on category I evidence

  • B—Directly based on category II evidence or extrapolated recommendation from …

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