Non-steroidal Anti-inflammatory Drugs for Pain Management in Fractures

When the Southlake Regional Health Centre in Newmarket, Ontario, reached an impasse over a drug treatment protocol, CADTH was contacted for some unbiased, evidence-based assistance.

The Medical Advisory Committee of this health care centre was developing a new medical directive for pain management of patients in the emergency department. An issue arose when it came to patients with fractures. While some physicians believed non-steroidal anti-inflammatory drugs (NSAIDs) should be incorporated into the treatment protocol, others held the view that NSAIDs impair fracture healing.

To help the committee come to a decision, Dr. Stephen Cluff, their Emergency Program Medical Director, requested that CADTH’s Health Technology Inquiry Service (HTIS)provide an evidence-based report on the relationship between NSAIDs and fracture healing.

CADTH’s analysis of the literature published on the topic since 2000 revealed that the evidence of a relationship between non-union of fractures and NSAID use is weak. The number of studies on the topic is small and there are methodological shortcomings within each study. It also revealed that concern about fracture healing and NSAID use appears to be based on animal studies, with little human data to support these concerns.

CADTH’s summary of acute pain management guidelines suggested NSAIDs were recommended as an initial treatment option for mild to moderate pain. When used concurrently with opioids in patients with moderate to severe pain, NSAIDs can reduce opioid requirements, thereby translating to lower incidences of opioid-related adverse effects such as nausea, vomiting, dizziness, and constipation.

The CADTH report, said Dr. Cluff, provided the information the Medical Advisory Committee needed to make an informed decision. The majority of committee members voted in favour of incorporating NSAIDs into their new Medical Directive for Pain in the Emergency Room.

In 2006, nearly 73,000 people sought treatment in Ontario emergency departments for bone or joint fractures or dislocations.

The report is available to Canadian health care decision makers in the federal government, provincial health ministries, Local Health Integration Networks, regional health authorities, hospitals, and national and federal health care programs in CADTH member jurisdictions: http://cadth.ca/index.php/en/hta/programs/htis