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Ms McSwan points pharmacists to refer to the guideline, which is easy to read. In addition, Ms McSwan notes that it’s important to also look at the muscle, tissue, skin and bone system around the affected joints and understand fear-avoidance behaviour. “Especially important is understanding how people fear movement, which results in tense muscles which can increase the pain experience in osteoarthritis of the hip or lower back.” “The old way of looking at osteoarthritis was all about focusing on the cartilage loss between bones only. Well, that’s not considering the whole picture. Instead we want to look at it more comprehensively – a consideration that is very important.” She concludes by saying that pharmacists in the community are well placed to advise patients living with osteoarthritis on the enablers and limiters of their condition as this context assists both the pharmacist and the patient to decipher what will optimise improvement and what is injurious. Applying principles of osteoarthritis to lower back pain Like osteoarthritis, low back pain (LBP) is one of the most commonly presenting body pain conditions in the Australian healthcare setting.3 Similarly to osteoarthritis, treatment of LBP should begin with the implementation of non-pharmacological strategies where appropriate. Pharmacological management can be introduced to reduce the severity of symptoms and help minimise the risk of acute cases transforming into chronic cases.3-6 In almost all cases, LBP does not have a known pathoanatomical cause and as a result there are no specific LBP treatments. However, LBP often results in inflammation in the surrounding muscle.3,7 In a recent review comparing the Australian and international LBP management guidelines on paracetamol vs NSAIDs, the authors noted the growing shift towards the adoption of NSAIDs in LBP treatment across the world and that Australian clinical guidelines position NSAIDs as a first-line treatment option in suitable patients.3,7 *Refer to guidelines for a full list of recommendations. Evidence for ibuprofen as an oral pain-reliever A study examining published Cochrane reviews to analyse the efficacy of over-the-counter oral analgesics for acute pain concluded that evidence is strong for combinations of ibuprofen and paracetamol, with fast acting formulations of ibuprofen 200mg and 400mg also having good pain relief success rates.8 According to the Moore et al. Cochrane review, the proportion of participants achieving at least 50 per cent maximum pain relief over six hours was 45 per cent for ibuprofen 400 mg (NNT = 2.5, range 2.7 to 3.2), while for ibuprofen 200 mg + paracetamol 500 mg it was 69 per cent (NNT = 1.6, range 1.5 to 1.8).8 NNT = number needed to treat for one more person to have good pain relief than if the same number were treated with placebo. Nurofen 400 Double Strength contains 400mg ibuprofen. For the temporary relief of pain. Nuromol contains 200 mg ibuprofen and 500 mg paracetamol. For the temporary relief of pain and inflammation. References: 1. Australian Government. Australian Institute of Health and Welfare. Osteoarthritis. Available from: https://www.aihw.gov. au/reports/chronic-musculoskeletal-conditions/osteoarthritis/contents/what-is-osteoarthritis (accessed 21 December 2020). 2. The Royal Australian College of General Practitioners. Guideline for the management of knee and hip osteoarthritis. 2nd edn. East Melbourne, Vic: RACGP, 2018. 3. Mishriky J, et al. Pharmacy Practice 2020;18(3):2075. 4. Oliveira CB, et al. Eur Spine J. 2018;27(11):2791-2803. 5. Low back pain and sciatica in over 16s: assessment and management. London: NICE; 2016. 6. Qaseem A, et al. Ann Intern Med 2017;166 (7):514-530. 7. eTG complete. Low back pain. Available at: https://tgldcdp.tg.org.au/ (accessed 21 December 2020). 8. Moore RA, et al. Cochrane Database Syst Rev. 2015 Nov; 2015(11): CD010794. Published online 2015 Nov 4. doi: 10.1002/14651858.CD010794.pub2. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6485506/ (accessed 21 December 2020). Reckitt Benckiser Group of Companies. Level 47, 680 George St, Sydney 2000, NSW Australia. Prepared January 2021. RB0165