Gastrointestinal effects of NSAIDs. Difficulties in detection and management

Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid are effective analgesic agents, but their use carries a significant potential for gastrointestinal side effects. Because many persons who have serious adverse effects from NSAIDs are asymptomatic, the decision to use these drugs must be tempered by an understanding of the side-effect profile and knowledge of who constitutes the high-risk population. Patients must be vigilantly monitored for signs and symptoms of reactions to the drugs, which should be discontinued when injury is suspected if at all possible. Diagnostic endoscopy should be the mainstay of further evaluation. Treatment of NSAID-induced gastrointestinal disease parallels that of non-NSAID-related reactions. This includes use of histamine2 receptor antagonists or proton pump inhibitors. Although NSAID-induced ulcers can heal while the drugs are continued, only omeprazole (Prilosec) has been shown to speed healing during NSAID use. For persons at highest risk, consideration must be given to prophylaxis against peptic ulcer disease. Misoprostol (Cytotec) has been clearly shown to offer the best protection against gastroduodenal ulceration.     

Improving the gastrointestinal safety of NSAIDs: the development of misoprostol--from hypothesis to clinical practice

Arthritis is a major source of disability for the American population. It results in significant morbidity for the millions of patients affected and costs billions of dollars yearly for diagnosis and management. Nonsteroidal antiinflammatory drugs (NSAIDs) are the principal therapy for the majority of arthritis patients. It has been estimated that more than 15 million people with arthritis take these drugs daily. This use is predicted to increase greatly not only as a result of an aging population, with the consequent increase in the prevalence of arthritis, but also because NSAIDs may prove to have a role in decreasing colonic neoplasia and in reducing the likelihood of conditions such as Alzheimer's disease. It is therefore increasingly important to understand the nature of the side effects associated with these agents as well as ways of decreasing or preventing their occurrence. NSAIDs inhibit the enzymes cyclooxygenase-1 and cyclooxygenase-2. This reduces the synthesis of prostaglandins and therefore decreases joint inflammation, but it may also lead to the development of gastric and duodenal ulcers. For this reason, exogenous prostaglandins have been studied for their potential role in preventing NSAID-associated ulcers and ulcer complications. This paper reviews the development of the prostaglandin E1 analog misoprostol, the theory behind its use as a mucosal protective agent, and the results of studies in animals as well as in normal volunteers and patients with arthritis. Ultimately, a study was performed to evaluate whether misoprostol reduces the incidence of serious ulcer complications in patients taking NSAIDs. It is an interesting story, which promises to be of increasing importance as NSAID use expands to new indications while concern remains about their associated complications, especially those related to the gastrointestinal tract.     

Physiologically relevant one-compartment pharmacokinetic models for skin. 2. Comparison of models when combined with a systemic pharmacokinetic model

The discovery of a second isoform of cyclooxygenase (cyclooxygenase-2) that is expressed in inflammatory cells and the central nervous system, but not in the gastric mucosa, offers the possibility of developing anti-inflammatory and analgesic agents that lack the gastrointestinal side effects of currently available nonsteroidal anti-inflammatory drugs. Lead compounds from several different structural classes have been identified and shown to be slow, tight-binding inhibitors that express their selectivity for cyclooxygenase-2 in the time-dependent step. The determination of structures of enzyme-inhibitor co-crystals along with site-directed mutagenesis experiments reveal the molecular basis for selectivity of some, but not all, inhibitors. Preclinical and clinical studies suggest cyclooxygenase-2 inhibitors are highly promising new agents for the treatment of pain and inflammation, and for the prevention of cancer.     

Exacerbation of inflammation-associated colonic injury in rat through inhibition of cyclooxygenase-2

Cyclooxygenase type 1 is constitutively expressed and accounts for synthesis of prostaglandins in the normal gastrointestinal tract. Cyclooxygenase-2 is expressed at sites of inflammation. Selective inhibitors of cyclooxygenase-2 have been suggested to spare gastrointestinal prostaglandin synthesis, and therefore lack the ulcerogenic effects associated with standard nonsteroidal antiinflammatory drugs. However, the effects of cyclooxygenase-2 inhibitors on inflamed gastrointestinal mucosa have not been examined. We examined cyclooxygenase-2 mRNA and protein expression before and after induction of colitis in the rat, the contribution of cyclooxygenase-2 to colonic prostaglandin synthesis during colitis and the effects of selective inhibitors of cyclooxygenase-2 on colonic injury in this model. Cyclooxygenase-2 mRNA expression increased three to sixfold during the period 24 h to 1 wk after induction of colitis, with marked increases in cyclooxygenase-2 protein expression in the lamina propria and muscularis of the colon during colitis. Cyclooxygenase-1 expression (mRNA and protein) was not affected by the induction of colitis. The prostaglandins produced during colitis were largely derived from cyclooxygenase-2. Treatment with selective cyclooxygenase-2 inhibitors resulted in exacerbation of colitis, with perforation occurring when the compounds were administered for a week. These studies demonstrate that suppression of cyclooxygenase-2 can result in exacerbation of inflammation-associated colonic injury.     

Strychnine-insensitive [3H] glycine binding to synaptosomal membranes from the chick retina

PURPOSE: Both isoforms of cyclo-oxygenase, COX-1 and COX-2, are inhibited to varying degrees by all of the available nonsteroidal anti-inflammatory drugs (NSAIDs). Because inhibition of COX-1 by NSAIDs is linked to gastrointestinal ulcer formation, those drugs that selectively inhibit COX-2 may have less gastrointestinal toxicity. We measured the extent to which NSAIDs and other anti-inflammatory or analgesic drugs inhibit COX-1 and COX-2 in humans. SUBJECTS AND METHODS: Aliquots of whole blood from 16 healthy volunteers were incubated ex vivo with 25 antiinflammatory or analgesic drugs at six concentrations ranging from 0 (control) to 100 microM (n = 5 for each). Blood was assayed for serum-generated thromboxane B2 synthesis (COX-1 assay) and for lipopolysaccharide-stimulated prostaglandin E2 synthesis (COX-2 assay). In addition, gastric biopsies from the same volunteers were incubated with each drug ex vivo and mucosal prostaglandin E2 synthesis measured. RESULTS: Inhibitory potency and selectivity of NSAIDs for COX-1 and COX-2 activity in blood varied greatly. Some NSAIDs (eg, flurbiprofen, ketoprofen) were COX-1 selective, some (eg, ibuprofen, naproxen) were essentially nonselective, while others (eg, diclofenac, mefenamic acid) were COX-2 selective. Inhibitory effects of NSAIDs on gastric prostaglandin E2 synthesis correlated with COX-1 inhibitory potency in blood (P < 0.001) and with COX-1 selectivity (P < 0.01), but not with COX-2 inhibitory potency. Even COX-2 "selective" NSAIDs still had sufficient COX-1 activity to cause potent inhibitory effects on gastric prostaglandin E2 synthesis at concentrations achieved in vivo. CONCLUSION: No currently marketed NSAID, even those that are COX-2 selective, spare gastric COX activity at therapeutic concentrations. Thus, all NSAIDs should be used cautiously until safer agents are developed.     

Prevention of gastrointestinal cancer--the potential role of NSAIDs in colorectal cancer

Gastrointestinal cancers are among the leading sites of cancer and leading causes of cancer-related deaths. Gastrointestinal cancers are often at an advanced stage at the time of diagnosis, and are highly resistant to non-surgical therapy. Thus early diagnosis and prevention are approaches that are under active investigation. Screening and surveillance are considered secondary prevention. Primary prevention is the use of dietary or environmental modification or chemopreventive agents. This written review will emphasize the potential role of acetylsalicylic acid and other non-steroidal anti-inflammatory drugs (NSAIDs) in the prevention of gastrointestinal cancer, and specifically colorectal cancer. Cell culture and animal studies have shown that NSAIDs possess anti-proliferative and anti-neoplastic effects. Recent epidemiologic surveys also suggest that individuals who regularly take NSAIDs, particularly acetylsalicylic acid, have about a 50% decrease in colorectal cancer incidence and mortality. However, in the only interventional trial of aspirin (and beta-carotene), a retrospective analysis had inadequate statistical power to demonstrate any protective effect against colorectal cancer. About a dozen small prospective intervention studies have been done in a total of about a hundred patients with familial adenomatous polyposis to test the efficacy of NSAIDs, particularly sulindac. All human trials have shown substantial partial and some complete regression of colorectal and perhaps also duodenal adenomatous polyps. But virtually all patients had regrowth of adenomatous polyps after sulindac was stopped. In addition, sulindac and other NSAIDs result in occasional adverse events such as gastrointestinal bleeding. Thus sulindac cannot be recommended for routine use outside of a study setting. One valid current approach to the prevention of gastrointestinal cancer, and colorectal cancer in particular, is the adoption of a healthy lifestyle and appropriate screening and surveillance. Screening and surveillance guidelines have been developed by several public agencies and their recommendations should be adopted. In addition, we should adopt a healthy lifestyle and diet, which consists of low fat ( < 30% to total calories), and high fiber (> 3 daily servings of fruits/vegetables), with the avoidance of red meats ( < 3 weekly servings) and alcohol ( < 2 drinks daily), and the absolute avoidance of tobacco smoking.     

New cyclooxygenase-2/5-lipoxygenase inhibitors. 1. 7-tert-buty1-2,3-dihydro-3,3-dimethylbenzofuran derivatives as gastrointestinal safe antiinflammatory and analgesic agents: discovery and variation of the 5-keto substituent

A series of 5-keto-substituted 7-tert-buty1-2,3-dihydro-3,3- dimethylbenzofurans (DHDMBFs) were prepared and evaluated as potential nonsteroidal antiinflammatory and analgesic agents. Interest in this class of compounds arose when a DHDMBF was found to be an active metabolite of the di-tert-butylphenol antiinflammatory agent tebufelone. We have now found that a variety of 5-keto-substituted DHDMBFs have good in vivo antiinflammatory and analgesic activity after oral administration. These compounds inhibit both cyclooxygenase (COX) and 5-lipoxygenase (5-LOX) in vitro. The cyclooxygenase inhibition was found to be selective for the cyclooxygenase-2 isoform, and this combination of COX-2/5-LOX inhibition may be responsible for the gastrointestinal safety of compounds such as 30.     

Inflammatory processes and antiinflammatory drugs in Alzheimer's disease: a current appraisal

The study of risk factors and protective influences can yield clues to the pathogenesis of Alzheimer's disease (AD). Intervention on such factors can effect disease prevention or treatment while etiology remains unknown. Most known AD risk factors offer no prospect of prevention, but 14 of 15 relevant publications since 1987 suggest that the symptoms of AD are prevented or attenuated by antiinflammatory treatments. These findings are supported by numerous circumstantial findings suggesting a role for cytokines and acute phase reactants in the pathogenesis of AD. In particular, activated microglia and/or reactive astrocytes, found within or near all AD lesions, are thought to kill target cells by using either free radicals or the classical complement pathway. These mechanisms should be suppressed by glucocorticoids, but the available data suggest that nonsteroidal antiinflammatory drugs (NSAIDs) exert a stronger protective influence than steriods. NSAIDs (but not steroids) suppress the action of cyclooxygenases (COX), which catalyze synthesis of prostaglandins. The latter are intermediaries in the postsynaptic signal transduction cascade of cells with NMDA-type glutamate receptors. They may also potentiate glutamatergic transmission by inhibiting astrocytic reuptake of glutamate. Both mechanisms can potentiate excitotoxic cell death. Further work is needed to clarify whether steroids, NSAIDs, or both prevent or attenuate the symptoms of AD.     

Efficacy and safety of nonsteroidal antiinflammatory drugs for cancer pain: a meta-analysis

PURPOSE: To assess the efficacy and safety of nonsteroidal antiinflammatory drugs (NSAIDs) in the treatment of cancer pain by meta-analyses of the published randomized control trials (RCTs). PATIENTS AND METHODS: Twenty-five studies met inclusion criteria for analysis. Of these, 13 tested a single-dose effect, nine multiple-dose effects, and three both single- and multiple-dose effects of 16 different NSAIDs in a total of 1,545 patients. Baseline pain intensity (when provided) of moderate or higher was indicated in 81% of patients. RESULTS: Single-dose NSAID studies found greater analgesic efficacy than placebo, with rough equivalence to 5 to 10 mg of intramuscular morphine. Pain scores differed insignificantly for aspirin versus three other NSAIDs. Analgesic responses to low- and high-dose NSAIDs suggested a dose-response relationship, but this was not statistically significant. Recommended and supramaximal single doses of three NSAIDs produced comparable changes in pain scores, which indicates a ceiling analgesic effect. Common side effects included upper gastrointestinal symptoms, dizziness, and drowsiness. The incidence of side effects showed a trend to increase with dose, without a ceiling effect, and to increase with multiple doses. Single or multiple doses of weak opioids (WO) alone or in combination (WO/C) with nonopioid analgesics did not produce greater analgesia than NSAIDs alone. Single doses of WO/C analgesics produced more side effects than NSAIDs alone, although both side effect incidence and patient dropout rates were equal when multiple doses were administered. CONCLUSION: These findings question whether the traditional World Health Organization (WHO) second analgesic step (addition of a weak opioid when pain is inadequately treated by a nonopioid analgesic alone) is warranted. A lack of comparable studies precluded testing the hypothesis that NSAIDs are particularly effective for malignant bone pain.     

New non-steroidal anti-rheumatic drugs: selective inhibitors of inducible cyclooxygenase

MODE OF ACTION OF NON-STEROIDAL ANTI-INFLAMMATORY DRUGS: Non-steroidal anti-inflammatory drugs (NSAID) exert their major therapeutic and adverse effects by inhibition of prostanoid synthesis. Also the interactions with antihypertensive drugs and lithium are caused by this mechanism of action. Cyclooxygenation is a key enzymatic step in the synthesis of prostanoids. 1990 2 isoforms of the enzyme cyclooxygenase have been identified: Prostanoids synthesized by the constitutive cyclooxygenase (COX-1) are involved in physiological homeostasis. In contrast, the inducible cyclooxygenase (COX-2) produces large amounts of prostanoids, mainly contributing to the pathophysiological process of inflammation. COX-2 SELECTIVE NSAID: The discovery of the cyclooxgenase-isoenzymes ushered in a new generation of NSAID: A drug with selectivity for COX-2 would inhibit proinflammatory prostanoid synthesis while sparing physiologic prostanoid synthesis. Thus, a selective COX-2 inhibitor should be anti-inflammatory with less or no gastrointestinal or other NSAID-typical adverse effects. The experiences with currently used NSAID, which show an increasing incidence of side effects as COX-1 inhibition increases, and studies with the COX-2 selective NSAID salsalate and meloxicam, which have less adverse effects than nonselective COX inhibitors in equivalent antiphlogistic dosage, prove the concept of selective COX-2 inhibition to avoid the NSAID typical side effects. Newly developed drugs with a very high selectivity for COX-2 are now tested in clinical trials. CONCLUSION: So far the results suggest, that selective and highly selective COX-2 inhibitors have significantly fewer gastrointestinal and renal adverse effects and do not inhibit platelet aggregation.     

Nonsteroidal anti-inflammatory drugs and corticosteroids for the management of canine osteoarthritis

Anti-inflammatory medications have long been prescribed for relief of the pain and discomfort associated with OA. This occurs despite the recognized side effects associated with use of NSAIDs and corticosteroids. Available evidence suggests that NSAIDs provide this relief through a combination of central and peripheral actions. Recent discovery of two isoforms of cyclooxygenase has increased our understanding of NSAID activity and may result in identification of drugs that potentially will have fewer side effects. A review of NSAIDs used in veterinary medicine indicates that relatively little is known regarding their role in treating OA, although controlled studies involving carprofen and etodolac have increased our knowledge of the efficacy of specific NSAIDs used for this purpose.     

Renal side-effects of non-steroidal antirheumatic drugs

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAID) are increasingly used for analgesia, as antirheumatics and to inhibit platelet aggregation. Renal side effects occur mainly in patients at risk, e.g. those with pre-existing renal insufficiency, or when used together with diuretics or a second NSAID. PATIENTS: In these patients, reversible impairment of renal function, disturbance of electrolyte homeostasis, edema and hypertension are quite common. Nephrotic syndrome with or without interstitial nephritis and renal failure is a rare complication of long-term NSAID therapy. Analgesic nephropathy may result from chronic NSAID use. These three renal complications are exemplified by case reports. CONCLUSIONS: Since side effects of NSAIDs are initially reversible, careful observation of patients can prevent chronic illness. Only rarely dialysis or treatment with glucocorticoids is indicated in patients with interstitial nephritis. Given the large number of patients taking NSAIDs, however, renal side effects are rare, and usually have no long-term consequences. Nevertheless, early detection of side effects is of importance for the prevention of long-term medical complications.     

An update on eicosanoids and inhibitors of cyclooxygenase enzyme systems

There are 3 main enzymatic pathways for synthesis of eicosanoids from arachidonic acid, however, some compounds are also formed non-enzymatically. Among the enzymatic pathways, cyclooxygenase (COX) also known as prostaglandin synthase (PGHS), generates endoperoxides (PGG/H). These are converted into prostaglandins (PGs) and thromboxanes (TXs). The second pathway involves lipooxygenase (LOX) group of enzymes to provide hydroperoxyeicosatetraenoic acid (HpETEs) which in turn can be converted into leukotrienes (LTs), hepoxilins (HXs), trioxilins and lipoxins (LXs). The third pathway involves cytochrome P-450 which catalyses the formation of a number of monohydroxy fatty acids (hydroxyeicostetraenoic acids or HETEs) dihydroxy fatty acids (dihydroxyeicostetrienoic acids or DiHETrEs) and epoxyeicosatrienoic acids (EpETrEs: formerly called EETs). This system also provides leukotoxins. The non-enzymatic pathway leads to the formation of isoprostanes by free radical catalysed peroxidation of arachidonic acid. In addition, brain cells also convert arachidonic acid into arachidonylethanolamide (anandamide) which have the ability to bind to cannabinoid receptors. Most of these eicosanoids are either biologically active or are converted into metabolites which have biological activities. Cyclooxygenase is now known to exist in two separate isoforms which are called COX-1 and COX-2. While both isoforms catalyse the same reactions, the former is a constitutive enzyme and its activity is not markedly changed once the cell is fully grown. The later isoform is however inducible and its activity is several fold increased following the exposure of body cells to a number of stimuli and its contribution in the process of inflammation is now well documented. It is now believed that eicosanoids produced by COX-1 activity are essential for the physiological (house keeping) functions while those produced by COX-2 lead to various pathological changes in body tissues. Older nonsteroidal antiinflammatory drugs like aspirin and indomethacin are non selective inhibitors of COX activity and therefore, in addition to inhibiting COX-2 activity, inhibit the formation of eicosanoids by COX-1. The later are required for normal house keeping functions such as secretion of mucus for protection of gastrointestinal mucosa, maintenance of renal function and control of haemostasis. Use of older non-selective NSAIDs has been associated with a number of gastrointestinal, renal and other side effects. Recently drugs such as nimesulide and meloxicam with selective action on COX-2 have been discovered and introduced into medicine. Evidence available so far has indicated the low incidence of side effects with these drugs. While being useful for various arthritic and other conditions, it is unlikely that these drugs will replace aspirin for the cardiovascular disease.     

New NSAIDS: COX-1, COX-2, what about them?

Non steroidal antiinflammatory (NSAID) drugs are the most widely prescribed drugs against pain and inflammation. Problems of tolerance, particularly gastrointestinal toxicity, limit their use. The central mechanism of NSAID action is the reduction of prostaglandin production from arachidonic acid through cyclooxygenase inhibition. Although such a mechanism was already described 25 years ago, the recent discovery of two isoforms of cyclooxygenase, the cyclooxygenase 1 (COX-1) constitutively expressed in most tissues and the cyclooxygenase 2 (COX-2), inducible, has prompted research in developing new NSAID that would be safer whilst maintaining their efficacy. Nevertheless, their long term efficacy and safety need to be demonstrated in clinical practice. There are still unsolved questions, especially about the physiological role of COX-2.     

Influence of mode of delivery on twin births

One of the most deleterious side effects of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) is gastric injury. In order to prevent this, attempt has been made to make novel nitric oxide (NO) releasing NSAIDs. The NO-releasing moiety (nitroxybutylester), which is combined with NSAIDs, has been shown to be responsible for gastrointestinal protection. Various NO-releasing NSAIDs have been compared with their parent compounds and marked decrease in gastrointestinal side effects were observed in the former case. Various animal studies have been done in this context. However, exact mechanism of action of NO-releasing NSAIDs is not clear.     

Nonsteroidal antiinflammatory drugs and uncoupling of mitochondrial oxidative phosphorylation

OBJECTIVE: There is a lack of correlation between cyclooxygenase (COX) inhibition and nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal (GI) damage; it has been suggested that mucosal damage may be initiated by a "topical" action of NSAIDs involving mitochondrial injury. We evaluated the effect of a range of NSAIDs and related compounds on mitochondrial function and assessed the differences between them in relation to their physicochemical properties. METHODS: Stimulation of respiration, as an indicator of mitochondrial uncoupling, was measured in isolated coupled rat liver mitochondrial preparations, using an oxygen electrode. RESULTS: Conventional NSAIDs and acidic prodrugs all had stimulatory effects on mitochondrial respiration at micromolar concentrations (0.02-2.7 microM); higher concentrations were inhibitory. The uncoupling potency was inversely correlated with drug pKa (r = -0.87, P < 0.001; n = 12). Drugs known to have good GI tolerability, including modified flurbiprofen (dimero-flurbiprofen and nitrobutyl-flurbiprofen), nabumetone (a non-acidic prodrug), and non-acidic highly selective COX-2 inhibitors, did not cause uncoupling. CONCLUSION: The ability to uncouple mitochondrial oxidative phosphorylation is a common characteristic of antiinflammatory agents with an ionizable group. Modification or absence of an ionizable moiety reduces the effect on mitochondria and could lead to improved NSAID GI safety.     

Aspirin-like molecules that covalently inactivate cyclooxygenase-2

Many of aspirin's therapeutic effects arise from its acetylation of cyclooxygenase-2 (COX-2), whereas its antithrombotic and ulcerogenic effects result from its acetylation of COX-1. Here, aspirin-like molecules were designed that preferentially acetylate and irreversibly inactivate COX-2. The most potent of these compounds was o-(acetoxyphenyl)hept-2-ynyl sulfide (APHS). Relative to aspirin, APHS was 60 times as reactive against COX-2 and 100 times as selective for its inhibition; it also inhibited COX-2 in cultured macrophages and colon cancer cells and in the rat air pouch in vivo. Such compounds may lead to the development of aspirin-like drugs for the treatment or prevention of immunological and proliferative diseases without gastrointestinal or hematologic side effects.     

Purification and characterization of a phagocytosis inducing factor: role in cell-substratum adherence

There is a wealth of evidence that nonsteroidal anti-inflammatory drugs (NSAIDs) can prevent colorectal cancer. In this article the role of cyclooxygenase 1 and 2, the principle target of NSAIDs, in the development of colorectal cancer is reviewed. Cyclooxygenase is constitutively expressed in normal colonic epithelium and surrounding stroma and could catalyse the generation of malondialdehyde which is a known mutagen and could initiate colorectal carcinogenesis. Mutation of APC which is an early genetic event leads to the expression of cyclooxygenase 2 which may prevents the appropriate apoptosis of mutant adenoma cells. Other proneoplastic effects of cyclooxygenase include changing the action of Transforming Growth Factor beta from anti-proliferative to pro-proliferative, reducing adherence to extracellular matrix, promotes metastasis and angiogenesis. These properties of cyclooxygenases suggest that inhibition of both isoforms may have important protective effects against colorectal cancer.     

Topical NSAIDs for musculoskeletal conditions. A review of the literature

In recent years a growing number of topical nonsteroidal anti-inflammatory drugs (NSAIDs) have become available. This has been prompted in large part by the high incidence of serious gastrointestinal adverse events associated with the use of systemic NSAIDs, and the premise that minimisation of plasma concentrations of active drug may result in fewer systemic adverse effects. Evidence in humans and animals with topical NSAIDs demonstrates lower plasma concentrations than with systemically administered drugs, while those in soft tissues are still of a magnitude considered consistent with exerting an anti-inflammatory effect. In joints, however, the evidence is less strong, and there is still dispute whether in this case the drug reaches the joint predominantly via the transcutaneous or systemic route. There has been a sufficient number of studies of soft tissue conditions to demonstrate the superiority of topical NSAIDs over placebo and to suggest equivalent efficacy in comparison with some oral NSAIDs. For arthropathies, however, the literature is more sparse. Although several studies claim a benefit for topical NSAIDs against placebo, the results are less conclusive and further study is required. Trials of topical agents against intra-articular corticosteroids and rubefacients are either lacking or inconclusive. The adverse event profile of topical agents is reasonable: minor cutaneous effects occur in up to 2% of patients but tend to be self-limiting. Gastrointestinal events appear from the existing literature to be infrequent and minor, although long term studies are required. Bronchospasm and renal impairment have been reported and may be more frequent in patients who have experienced these effects with oral agents. The initial costs of topical agents tend to be higher than those of oral agents but a cost-effectiveness analysis suggests an overall benefit: this issue requires further clarification.