When low back pain strikes, many people turn to non-steroidal anti-inflammatory drugs (NSAIDs), like naproxen and ibuprofen, or their newer COX-2 inhibitor cousin Celebrex. However, these drugs work no better than old faithful acetaminophen (Tylenol), according to a new review of studies.
Review data “support guidelines for the management of low back pain in primary care that recommend NSAIDs as a treatment option after paracetamol has been tried, since there are fewer side effects with paracetamol,” said lead reviewer Pepijn Roelofs. Paracetamol is the European version of Tylenol.
The researchers examined 65 studies, covering more than 11,000 low back pain sufferers. They concluded that NSAIDs are “slightly effective” for short-term symptomatic relief, allowing a return to normal activity in patients with acute and chronic low back pain without sciatica.
The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
The authors cautioned doctors that while NSAIDs are appropriate for short-term use, improvements are small and it is unclear whether they work better than simple analgesics or other drugs. No kind of NSAID jumped out as any more effective than others are, either, in the studies reviewed.
Moreover, the data showed that NSAIDs were not superior to acetaminophen.
“Currently, 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 and myocardial infarction,” said Roelofs, a doctoral student at the Erasmus University Medical Centre in Rotterdam.
The researchers also looked at studies on the narcotics and muscle relaxants, finding that NSAIDs did not bring more relief, but did have fewer side effects.
NSAIDs have both painkilling and inflammation-quelling properties, but they can cause stomach upset or even ulcers. COX-2 inhibitor class drugs can result in fewer stomach problems, but the makers of the COX-2 inhibitor Vioxx pulled the drug from the market in 2004 after several reports of cardiovascular problems related to its use.
The review found that NSAIDs had more side effects than placebos. However, COX-2 drugs had fewer gastric side effects than other NSAIDs.
The researchers looked at “non-specific” low back pain; that is, pain not resulting from arthritis or sciatica.
“There is conflicting evidence,” the researchers said, “that NSAIDs are more effective than simple analgesics and bed rest, and moderate evidence that NSAIDS are not more effective than other drugs, physiotherapy or spinal manipulation for low back pain.”
“It varies from individual to individual,” said Jon Levine, M.D., a professor of medicine at University of California San Francisco who was not affiliated with the review. “If one NSAID does not work, you can try another. This is often a very empirical situation. If it takes care of the pain, wouldn’t you take it?”
Pain relievers also come in combination or physicians prescribe more than one at a time, Levine said.
Reference: Roelofs PDDM, et al. Non-steroidal anti-inflammatory drugs for low-back pain. Cochrane Database of Systematic Reviews 2008, Issue 1.
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