Nonsteroidal anti-inflammatory drugs in the treatment of low back pain

Abstract

Low back pain (LBP) is amongst the top ten most common conditions presenting to primary care clinicians in the ambulatory setting. Further, it accounts for a significant amount of health care expenditure; indeed, over one third of all disability dollars spent in the United States is attributable to low back pain. In most cases, acute low back pain is a self-limiting disease. There are many evidence-based guidelines for the management of LBP. The most common risk factor for development of LBP is previous LBP, heavy physical work, and psychosocial risk factors. Management of LBP includes identification of red flags, exclusion of specific secondary causes, and comprehensive musculoskeletal/neurological examination of the lower extremities. In uncomplicated LBP, imaging is unnecessary unless symptoms become protracted. Reassurance that LBP will likely resolve and advice to maintain an active lifestyle despite LBP are the cornerstones of management. Medications are provided not because they change the natural history of the disorder, but rather because they enhance the ability of the patient to become more active, and in some cases, to sleep better. The most commonly prescribed medications include nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. Although NSAIDs are a chemically diverse class, their similarities, efficacy, tolerability, and adverse effect profile have more similarities than differences. The most common side effects of NSAIDs are gastrointestinal. Agents with cyclo-oxygenase 2 selectivity are associated with reduced gastrointestinal bleeding, but problematic increases in adverse cardiovascular outcomes continue to spark concern. Fortunately, short-term use of NSAIDs for LBP is generally both safe and effective. This review will focus on the role of NSAIDs in the management of LBP.

Acute nonspecific (musculoskeletal) low back pain Guidelines of the Russian Society for the Study of Pain (RSSP)

“…НПВП рекомендуются при острой скелетно-мышечной ПБ (средний уровень доказательности) [25,60]. Преимущество НПВП перед плацебо доказано в отношении уменьшения боли и незначительного ускорения выздоровления [61].…”

“…В настоящее время не установлено достоверного превосходства какого-либо одного НПВП над другими в отношении облегчения неспецифической (скелетно-мышечной) ПБ [61,62]. Селективные ингибиторы циклооксигеназы 2 (ЦОГ2) более безопасны в отношении возможного поражения желудочно-кишечного тракта (ЖКТ) [63].…”

Clinical guidelines «Rational use of nonsteroidal anti-inflammatory drugs (NSAIDs) in clinical practice»

“…Одной из наиболее важных областей применения НПВП является купирование острой или контроль хронической НБС [27][28][29][30]. По данным метаанализа 65 РКИ (n=11 237), НПВП при этой патологии достоверно эффективнее ПЛ по таким показателям, как снижение интенсивности боли, время полного прекращения боли, потребность в дополнительной аналгезии и восстановление функциональной активности [9].…”

Long-term Management of Low Back Pain with Opioids and Non-steroidal Anti-inflammatory Drugs in a Health System

“…2,5 There are also serious risks associated with long-term use of non-steroidal anti-inflammatory drugs (NSAIDs), a comparable analgesic, such as gastrointestinal bleeding and renal disease. 6 Within the context of these known risks and recommendations to use both classes primarily for acute pain (except cautionary use for select conditions when there is clear longitudinal symptom improvement), it is unclear how often opioids and NSAIDs are prescribed long-term despite potential risks. 6–9 This study compares long-term use of both classes for patients with non-cancer low back pain in a large healthcare system.…”