Formulations of topical diclofenac, ibuprofen, ketoprofen, piroxicam, and indomethacin demonstrated significantly higher rates of clinical success (more participants with at least 50% pain relief) than matching topical placebo (moderate or high quality data ). Benzydamine did not. Three drug and formulation combinations had NNTs for clinical success below 4. For diclofenac, the Emulgel® formulation had the lowest NNT of (95% CI to ) in two studies using at least 50% pain intensity reduction as the outcome . Diclofenac plasters other than Flector® also had a low NNT of ( to ) based on good or excellent responses in some studies. Ketoprofen gel had an NNT of ( to ), from five studies in the 1980s, some with less well defined outcomes. Ibuprofen gel had an NNT of ( to ) from two studies with outcomes of marked improvement or complete remission. All other drug and formulation combinations had NNT values above 4, indicating lesser efficacy .
A Cochrane review of the analgesic efficacy of paracetamol and ibuprofen in the treatment of post-operative pain, concluded that combinations of paracetamol plus ibuprofen provided better analgesia than either medicine alone. 12 It was also concluded that the combination treatment reduced the need for additional analgesia to be administered and reduced the risk of adverse events occurring. 12 A study of approximately 900 patients using paracetamol or ibuprofen, or a combination of the two, for the treatment of osteoarthritis of the knee found significantly more patients achieved pain control at ten days and at 13 weeks with the combination treatment compared to paracetamol alone, but there was not a statistically significant difference compared to using ibuprofen alone. 15 In contrast, a small study of 90 patients randomised to one of three treatment groups in an emergency department setting found that combination treatment with paracetamol and ibuprofen did not provide more effective pain relief following musculoskeletal injury compared to either medicine alone. 16
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