NSAIDs May Not Be Best Bet for Low Back Pain

January 25, 2008 — A review of the literature on drug relief for low back pain (LBP) suggests that the popular nonsteroidal anti-inflammatory drugs (NSAIDs) are no more effective than other drugs such as acetaminophen, narcotic analgesics, and muscle relaxants.The review, published in the January 23 online issue of Cochrane Database of Systematic Reviews, also found that NSAIDs had more adverse effects than placebo and acetaminophen but fewer effects than muscle relaxants and narcotic analgesics. In addition, evidence from the review suggests that no one NSAID is clearly more effective than another.

The review should spark debate among clinicians and policy makers who develop clinical guidelines, Pepijn Roelofs, a doctoral student at the Erasmus University Medical Centre in Rotterdam, the Netherlands, and lead reviewer, told Medscape Neurology and Neurosurgery.

“The results of this study support those guidelines for the management of acute LBP in primary care that recommend NSAIDs as a treatment option after paracetamol (the European version of Tylenol or acetaminophen) has been tried, since there are fewer side effects with paracetamol.”

Most Prescribed Medication Worldwide

NSAIDs are the most frequently prescribed medication worldwide, the review authors note. Current guidelines recommend the prescription of an NSAID as an option for symptomatic relief in the management of LBP. Most guidelines recommend NSAIDs as a treatment option after paracetamol has been tried. Goals for NSAID therapy include symptomatic relief and facilitation of early return to normal activities.

For this Cochrane review, researchers carried out searches of various databases, including MEDLINE (1966 – June 2007) and EMBASE (1988 – June 2007) for studies in English, German, and Dutch. Studies were assessed for methodologic criteria and clinical relevance before a final set of 65 studies (59 English and 6 German) that included 11,237 patients was selected. Of these studies, 28 (42%) were considered high quality.

Studies included in the review involved 1 or more types of NSAID. They included comparisons of NSAIDs with the following groups:

  • Placebo
  • Acetaminophen/paracetamol
  • Other drugs (eg, narcotic analgesics or muscle relaxants)
  • Another NSAID (eg, traditional drugs vs selective cyclooxygenase-2 [COX-2] inhibitors)
  • Another NSAID plus a muscle relaxant
  • Another NSAID plus B vitamin
  • Nondrug treatment

The studies were randomized controlled trials (RCTs; double-blind, single-blind, and open label) as well as double-blind controlled trials. Subjects in the studies were 18 years or older who had nonspecific LBP with or without sciatica. The review excluded studies that enrolled subjects with back pain caused by infection, neoplasm, metastasis, osteoporosis, rheumatoid arthritis, or fractures.

Outcome measures for the studies included the following:

  • Pain intensity (eg, Visual Analog Scale or Numerical Rating Scale)
  • Global measure (eg, overall improvement, proportion of patients recovered)
  • Back pain functional status
  • Return-to-work status
  • Adverse effects

The review found moderate evidence that NSAIDs are not much more effective than other drugs for acute LBP and have more adverse effects than paracetamol. “This review suggests that NSAIDs are effective for short term global improvement in patients with acute and chronic LBP without sciatica, although the effects are small,” said Dr. Roelofs.

Individual NSAIDs Equally Effective

The review also uncovered strong evidence that various types of NSAIDs, including the selective COX-2 inhibitors, are equally effective for acute LBP. It showed as well that COX-2 inhibitors had statistically significant fewer adverse effects than traditional NSAIDs.

The long-term use of NSAIDs is controversial because of cardiovascular adverse effects in patients with cardiovascular risk factors such as previous angina pectoris, heart failure, or myocardial infarction, said Dr. Roelofs. Well-designed studies evaluating these risks are lacking, he believes. “For patients without cardiovascular risk factors, probably the benefits of short term use of NSAIDs outweigh their potential cardiovascular adverse effects,” he said, although the decision as to which drug to prescribe should be a clinical decision made between the clinician and the patient based on individual circumstances.

An area for future research will likely be adverse effects of NSAIDs and pain involving sciatica, said Dr. Roelofs.

The study was supported by the Dutch Health Insurance Board. One of the review authors is a coordinating editor, and another review author is an editor with the Cochrane Back Review Group. Editors are required to conduct at least 1 Cochrane review. This requirement ensures that editors are aware of the processes and commitment needed to conduct reviews. This involvement does not seem to be a source of conflict of interest in the Cochrane Back Review Group. Any editor who is a review author is excluded from editorial decisions on the review in which they are contributors. The remaining review authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online January 23, 2008.


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