Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain: systematic review and network meta-analysis

Review (98 RCTs; n=15,134 & 69 different medicines or combinations) found uncertain comparative effectiveness and safety, thus until higher quality head to head RCTs are published, a cautious approach is recommended in use of analgesics to manage acute non-specific low back pain.

SPS commentary:

Low or very low confidence was noted in evidence for reduced pain intensity after treatment with aceclofenac plus tizanidine, pregabalin, and 14 other medicines compared with placebo. Low or very low confidence was noted for no difference between the effects of several of these medicines. Increased adverse events had moderate to very low confidence with tramadol, paracetamol plus sustained release tramadol, baclofen, and paracetamol plus tramadol compared with placebo. These medicines could increase the risk of adverse events compared with other medicines with moderate to low confidence.

NICE guidance on low back pain makes the following recommendations:

  • Do not offer paracetamol alone for managing low back pain.
  • Do not routinely offer opioids for managing acute low back pain.
  • Do not offer opioids for managing chronic low back pain.
  • Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors or tricyclic antidepressants for managing low back pain.
  • Do not offer gabapentinoids or antiepileptics for managing low back pain.

British Medical Journal

Resource links:

NICE guidance: Low back pain and sciatica