Intended for healthcare professionals

CCBYNC Open access

Rapid response to:


Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials

BMJ 2015; 350 doi: (Published 31 March 2015) Cite this as: BMJ 2015;350:h1225

Rapid Response:

Paracetamol systematic review: time to accept results and move on

We can understand Dr Adam and Dr Veal’s desire to see a different result; where the status of paracetamol as an effective pain medicine could at least be preserved for the elderly or those with chronic conditions. Unfortunately their case is not consistent with the data. Older people were not excluded from these studies and the lack of effect for osteoarthritis, a chronic condition, does not lend much hope to the belief that paracetamol would be effective for chronic back pain. We also do not hold out much hope for the view that we should continue with paracetamol, because while it may not work in general it may work for some. The difficulty with this subgroup argument is that the effect of paracetamol was close to zero in the back pain trials. In order to have a subgroup where paracetamol provides appreciable pain reduction we require a subgroup where paracetamol appreciably increases pain. We think this is unlikely.

We agree with Dr Montgomery that our review had an inconvenient result. We think we all would have preferred a result that supported the endorsement of paracetamol in guidelines as a simple low cost option for back pain and osteoarthritis. But our review shows that paracetamol does not have a clinically appreciable effect on pain in these conditions and we now have to think through the other options. As Mallen and Haye noted in the accompanying editorial to our review there are non-drug options provided by physiotherapists for these two conditions but in many health care systems it may be hard to access these services. Given the burden of osteoarthritis and back pain it would make sense to try to change that situation.

Competing interests: No competing interests

21 April 2015
Gustavo C Machado
PhD Student
Professor Chris G Maher, A/Professor Manuela L Ferreira
The George Institute for Global Health, Sydney Medical School, University of Sydney
PO Box M201, Missenden Road, Camperdown, Sydney, NSW 2050, Australia