Download Non-steroidal anti-inflammatory drugs for low back pain

Non-steroidal anti-inflammatory drugs for low back pain
Roelofs PDDM, Deyo RA, Koes BW, Scholten RJPM, van Tulder MW
Non-steroidal anti-inflammatory drugs for low-back pain
Non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently prescribed medications worldwide and are
commonly used for treating low-back pain. This review found 65 studies (including over 11,000 patients) of mixed
methodological quality that compared various NSAIDs with placebo (an inactive substance that has no treatment
value), other drugs, other therapies and with other NSAIDs. The review authors conclude that NSAIDs are slightly
effective for short-term symptomatic relief in patients with acute and chronic low-back pain without sciatica (pain and
tingling radiating down the leg). In patients with acute sciatica, no difference in effect between NSAIDs and placebo
was found.
The review authors also found that NSAIDs are not more effective than other drugs (paracetamol/acetaminophen,
narcotic analgesics, and muscle relaxants). Placebo and paracetamol/acetaminophen had fewer side effects than
NSAIDs, though the latter has fewer side effects than muscle relaxants and narcotic analgesics. The new COX-2
NSAIDs do not seem to be more effective than traditional NSAIDs, but are associated with fewer side effects,
particularly stomach ulcers. However, other literature has shown that some COX-2 NSAIDs are associated with
increased cardiovascular risk.
The review noted a number of limitations in the studies. Only 42% of the studies were considered to be of high
quality. Many of the studies had small numbers of patients, which limits the ability to detect differences between the
NSAID and the control group. There are few data on long term results and long-term side effects.
This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane
Collaboration, currently published in The Cochrane Database of Systematic Reviews 2011 Issue 10, Copyright
© 2011 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is
available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Roelofs PDDM, Deyo RA, Koes BW, Scholten RJPM, van Tulder MW. Nonsteroidal anti-inflammatory drugs for low back pain. Cochrane Database of Systematic Reviews 2008, Issue 1.
Art. No.: CD000396. DOI: 10.1002/14651858.CD000396.pub3
Editorial Group: This version first published online: April 24. 2000
Last assessed as up-to-date: October 17. 2007
Abstract
Background
Non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently prescribed medications
worldwide and are widely used for patients with low-back pain. Selective COX-2 inhibitors are currently
available and used for patients with low-back pain.
Objectives
The objective was to assess the effects of NSAIDs and COX-2 inhibitors in the treatment of non-specific
low-back pain and to assess which type of NSAID is most effective.
Search strategy
We searched the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled
Trials up to and including June 2007 if reported in English, Dutch or German. We also screened
references given in relevant reviews and identified trials.
Selection criteria
Randomised trials and double-blind controlled trials of NSAIDs in non-specific low-back pain with or
without sciatica were included.
Data collection and analysis
Two review authors independently extracted data and assessed methodological quality. All studies were
also assessed on clinical relevance, from which no further interpretations or conclusions were drawn. If
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data were considered clinically homogeneous, a meta-analysis was performed. If data were lacking for
clinically homogeneous trials, a qualitative analysis was performed using a rating system with four levels
of evidence (strong, moderate, limited, no evidence).
Main results
In total, 65 trials (total number of patients = 11,237) were included in this review. Twenty-eight trials
(42%) were considered high quality. Statistically significant effects were found in favour of NSAIDs
compared to placebo, but at the cost of statistically significant more side effects. There is moderate
evidence that NSAIDs are not more effective than paracetamol for acute low-back pain, but paracetamol
had fewer side effects. There is moderate evidence that NSAIDs are not more effective than other drugs
for acute low-back pain. There is strong evidence that various types of NSAIDs, including COX-2
NSAIDs, are equally effective for acute low-back pain. COX-2 NSAIDs had statistically significantly
fewer side-effects than traditional NSAIDs.
Authors' conclusions
The evidence from the 65 trials included in this review suggests that NSAIDs are effective for short-term
symptomatic relief in patients with acute and chronic low-back pain without sciatica. However, effect
sizes are small. Furthermore, there does not seem to be a specific type of NSAID which is clearly more
effective than others. The selective COX-2 inhibitors showed fewer side effects compared to traditional
NSAIDs in the RCTs included in this review. However, recent studies have shown that COX-2 inhibitors
are associated with increased cardiovascular risks in specific patient populations.
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