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01.03.2010 | Therapy in Practice

Pharmacological Management of Low Back Pain

verfasst von: Dr Roger Chou

Erschienen in: Drugs | Ausgabe 4/2010

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Abstract

Low back pain is one of the most common conditions encountered in clinical practice and medications are the most commonly used type of treatment. In most patients, low back pain is nonspecific, in that the pain cannot be reliably attributed to a specific condition or abnormality in the back. Although a number of medications are available to treat nonspecific low back pain, selecting a therapy can be a challenge because each one is associated with a unique set of benefits and harms. In addition, the evidence supporting the use of different medications varies, and issues such as costs and patient preferences may also affect treatment choices.

A guideline published in 2007 from the American Pain Society and the American College of Physicians on diagnosis and treatment of low back pain includes recommendations on the use of medications, based on the quality of supporting evidence and the estimated magnitude of benefits relative to harms. For most patients with low back pain, regardless of the duration of symptoms, paracetamol (acetaminophen) and NSAIDs are first-line options for pain relief. Opioids are more potent analgesics, but are not a first-line option due to their abuse potential. Skeletal muscle relaxants and benzodiazepines can be used as adjunctive medications for acute low back pain, but have a high incidence of sedation. Tricyclic antidepressants may be an option for chronic low back pain, but their effects on pain appear small or uncertain. Nonetheless, depression is common in patients with low back pain and should be treated appropriately.

When choosing medications for treatment of low back pain, practice guidelines provide a useful starting point for making decisions, but clinicians should base therapeutic choices on individualized consideration and discussion with patients regarding the potential benefits and risks.

Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006; 332(7555): 1430–4PubMedCrossRef

Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates. Spine 2006; 31(23): 2724–7PubMedCrossRef

Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain: frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine 1995; 20(1): 11–9PubMedCrossRef

Bair MJ, Robinson RL, Katon W, et al. Depression and pain comorbidity. Arch Intern Med 2003; 163(20): 2433–45PubMedCrossRef

Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299(6): 656–64PubMedCrossRef

Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: part II. Arthritis Rheum 2008; 58(1): 26–35PubMedCrossRef

Luo X, Pietrobon R, Sun SX, et al. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine 2004; 29(1): 79–86PubMedCrossRef

Stewart WF, Ricci JA, Chee E, et al. Lost productive time and cost due to common pain conditions in the US workforce. JAMA 2003; 290(18): 2443–54PubMedCrossRef

Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147(7): 478–91PubMed

10.

Cherkin DC, Wheeler KJ, Barlow W, et al. Medication use for low back pain in primary care. Spine 1998 Mar 1; 23(5): 607–14PubMedCrossRef

11.

Deyo RA. Drug therapy for back pain: which drugs help which patients? Spine 1996; 21(24): 2840–9PubMedCrossRef

12.

Deyo R, Diehl A. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med 1988; 3(3): 230–8PubMedCrossRef

13.

Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med 2002; 137(7): 586–97PubMed

14.

Underwood MR, Dawes P. Inflammatory back pain in primary care. Br J Rheumatol 1995; 34(11): 1074–7PubMedCrossRef

15.

van Tulder MW, Assendelft WJ, Koes BW, et al. Spinal radiographic findings and nonspecific low back pain: a systematic review of observational studies. Spine 1997; 22(4): 427–34PubMedCrossRef

16.

Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 2009; 373(9662): 463–72PubMedCrossRef

17.

Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine 2003; 28(6): 616–20PubMed

18.

Bigos SJ, Bowyer R, Braen R, et al. Clinical practice guideline 14: acute low back problems in adults. Rockville (MD): Agency for Healthcare Policy and Research, 1994

19.

Airaksinen O, Brox J, Cedraschi C, et al. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006; 15 Suppl. 2: s192–300PubMedCrossRef

20.

van Tulder M, Becker A, Bekkering T, et al. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006; 15 Suppl. 2: s169–91CrossRef

21.

Rudwaleit M, Metter A, Listing J, et al. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum 2006; 54(2): 569–78PubMedCrossRef

22.

de Graaf I. Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diagnostic tests. Spine 2006; 31(10): 1168–76PubMedCrossRef

23.

Katz JN, Dalgas M, Stucki G, et al. Degenerative lumbar spinal stenosis: diagnostic value of the history and physical examination. Arthritis Rheum 1995; 38(9): 1236–41PubMedCrossRef

24.

van den Hoogen HM, Koes BW, van Eijk JT, et al. On the accuracy of history, physical examination, and erythrocyte sedimentation rate in diagnosing low back pain in general practice: a criteria-based review of the literature. Spine 1995; 20(3): 318–27PubMedCrossRef

25.

Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol 1999; 246(10): 899–906PubMedCrossRef

26.

Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992; 268(6): 760–5PubMedCrossRef

27.

Devillé W, van der Windt D, Dzaferagic A, et al. The test of Lasegue: systematic review of the accuracy of diagnosing herniated discs. Spine 2000; 25(9): 1140–7PubMedCrossRef

28.

Modic MT, Obuchowski NA, Ross JS, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology 2005 Nov 1; 237(2): 597–604PubMedCrossRef

29.

Vroomen P, de Krom M, Knottnerus J. Predicting the outcome of sciatica at short-term follow-up. Br J Gen Pract 2002; 52(475): 119–23PubMed

30.

Pengel LHM, Herbert RD, Maher CG, et al. Acute low back pain: systematic review of its prognosis. BMJ 2003; 327(7410): 323–7PubMedCrossRef

31.

Pincus T, Burton AK, Vogel S, et al. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine 2002; 27(5): E109–20PubMedCrossRef

32.

Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthop Clin North Am 1991; 22(2): 263–71PubMed

33.

Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J 2003; 12(2): 149–65PubMed

34.

Davies RA, Maher CG, Hancock MJ. A systematic review of paracetamol for non-specific low back pain. Eur Spine J 2008; 17(11): 1423–30PubMedCrossRef

35.

Roelofs PDDM, Deyo RA, Koes BW, et al. Nonsteroidal anti-inflammatory drugs for low back pain. Spine 2008; 33(16): 1766–74PubMedCrossRef

36.

Milgrom C, Finestone A, Lev B, et al. Overexertional lumbar and thoracic back pain among recruits: a prospective study of risk factors and treatment regimens. J Spinal Disord 1993 Jun; 6(3): 187–93PubMedCrossRef

37.

Evans DP, Burke MS, Newcombe RG, et al. Medicines of choice in low back pain. Curr Med Res Opin 1980; 6(8): 540–7PubMedCrossRef

38.

Hickey RF. Chronic low back pain: a comparison of diflunisal with paracetamol. N Z Med J 1982 May 12; 95(707): 312–4PubMed

39.

Nadler SF, Steiner DJ, Erasala GN, et al. Continuous low-level heat wrap therapy provides more efficacy than ibuprofen and acetaminophen for acute low back pain. Spine 2002; 27(10): 1012–7PubMedCrossRef

40.

Wiesel S, Cuckler J, Deluca F, et al. Acute low back pain: an objective analysis of conservative therapy. Spine 1980; 5(4): 324–30PubMedCrossRef

41.

Towheed T, Judd M, Hochberg M, et al. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev 2006; 1: CD004257PubMed

42.

Wegman A, van der Windt D, van Tulder M, et al. Nonsteroidal antiinflammatory drugs or acetaminophen for osteoarthritis of the hip or knee? A systematic review of evidence and guidelines. J Rheumatol 2004; 31(2): 344–54PubMed

43.

Zhang W, Jones A, Doherty M. Does paracetamol (acetaminophen) reduce the pain of osteoarthritis? A meta-analysis of randomised controlled trials. Ann Rheum Dis 2004; 63(8): 901–7PubMedCrossRef

44.

Watkins PB, Kaplowitz N, Slattery JT, et al. Amino-transferase elevations in healthy adults receiving 4 grams of acetaminophen daily. JAMA 2006; 296(1): 87–93PubMedCrossRef

45.

Larson AM, Polson J, Fontana RJ, et al. Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. Hepatology 2005; 42(6): 1364–72PubMedCrossRef

46.

FitzGerald GA, Patrono C. The coxibs, selective inhibitors of cyclooxygenase-2. N Engl J Med 2001; 245(6): 433–42

47.

Kearney PM, Baigent C, Godwin J, et al. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of athero-thrombosis? Meta-analysis of randomized trials. BMJ 2006; 332(7553): 1302–8PubMedCrossRef

48.

Scott PA, Kingsley GH, Smith CM, et al. Non-steroidal anti-inflammatory drugs and myocardial infarctions: comparative systematic review of evidence from observational studies and randomised controlled trials. Ann Rheum Dis 2007; 66(10): 1296–304PubMedCrossRef

49.

Bradburn MJ, Deeks JJ, Berlin JA, et al. Much ado about nothing: a comparison of the performance of meta-analytical methods with rare events. Stat Med 2007; 26(1): 53–77PubMedCrossRef

50.

American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009; 57(8): 1331–46CrossRef

51.

Antman EM, Bennett JS, Daugherty A, et al. Use of non-steroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation 2007; 115(12): 1634–42PubMedCrossRef

52.

Hooper L, Brown TJ, Elliott R, et al. The effectiveness of five strategies for the prevention of gastrointestinal toxicity induced by non-steroidal anti-inflammatory drugs: systematic review. BMJ 2004; 329(7472): 948PubMedCrossRef

53.

Chou R, Fanciullo G, Fine P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10(2): 113–30PubMedCrossRef

54.

Deshpande A, Furlan A, Mailis-Gagnon A, et al. Opioids for chronic low-back pain. Cochrane Database Syst Rev 2007; 3: CD004959PubMed

55.

Martell BA, O’Connor PG, Kerns RD, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med 2007; 146(2): 116–27PubMed

56.

Hale ME, Ahdieh H, Ma T, et al., the Oxymorphone ERSG. Efficacy and safety of Opana ER (oxymorphone extended release) for relief of moderate to severe chronic low back pain in opioid-experienced patients: a 12-week, randomized, double-blind, placebo-controlled study. J Pain 2007; 8(2): 175–84PubMedCrossRef

57.

Katz N, Richard R, Harry A, et al. A 12-week, randomized, placebo-controlled trial assessing the safety and efficacy of oxymorphone extended release for opioidnaive patients with chronic low back pain. Curr Med Res Opin 2007; 23(1): 117–28PubMedCrossRef

58.

Furlan AD, Sandoval JA, Mailis-Gagnon A, et al. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ 2006; 174(11): 1589–94PubMedCrossRef

59.

Kalso E, Edwards JE, Moore RA, et al. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain 2004; 112(3): 372–80PubMedCrossRef

60.

Chou R, Clark E, Helfand M. Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain: a systematic review. J Pain Symptom Manage 2003; 26(5): 1026–48PubMedCrossRef

61.

Moore RA, McQuay HJ. Prevalence of opioid adverse events in chronic non-malignant pain: systematic review of randomised trials of oral opioids. Arthritis Res Ther 2005; 7(5): R1046–51PubMedCrossRef

62.

Chou R, Fanciullo G, Fine PG, et al. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors - a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain 2009; 10(2): 131–46PubMedCrossRef

63.

Webster L. Update on abuse-resistant and abuse-deterrent approaches to opioid formulations. Pain Med 2009; 10(S2): S124–33PubMedCrossRef

64.

Vorsanger G, Xiang J, Gana T, et al. Extended-release tramadol (tramadol ER) in the treatment of chronic low back pain. J Opioid Manage 2008; 4(2): 87–97

65.

Metscher B, Kubler U, Jahnel-Kracht H. Dexketoprofen-trometamol and tramadol in acute lumbago [in German]. Fortschr Med Orig 2001; 118(4): 147–51PubMed

66.

Muller FO, Odendaal CL, Muller FR, et al. Comparison of the efficacy and tolerability of a paracetamol/codeine fixed-dose combination with tramadol in patients with refractory chronic back pain. Arzneimittelforschung 1998; 48(6): 675–9PubMed

67.

Schnitzer TJ, Gray WL, Paster RZ, et al. Efficacy of tramadol in treatment of chronic low back pain. J Rheumatol 2000; 27(3): 772–8PubMed

68.

McDiarmid T, Mackler L, Schneider DM. Clinical inquiries: what is the addiction risk associated with tramadol? J Fam Pract 2005; 54(1): 72–3PubMed

69.

Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane Database Syst Rev 2005; 3: CD005454PubMed

70.

Salerno SM, Browning R, Jackson JL. The effect of anti-depressant treatment on chronic back pain: a meta-analysis. Arch Intern Med 2002; 162(1): 19–24PubMedCrossRef

71.

Staiger TO, Gaster B, Sullivan MD, et al. Systematic review of antidepressants in the treatment of chronic low back pain. Spine 2003; 28(22): 2540–5PubMedCrossRef

72.

Urquhart DM, Hoving JL, Assendelft WWJJ, et al. Antidepressants for non-specific low back pain. Cochrane Database Syst Rev 2008; 1: CD001703PubMed

73.

Atkinson JH, Slater MA, Wahlgren DR, et al. Effects of noradrenergic and serotonergic antidepressants on chronic low back pain intensity. Pain 1999; 83(2): 137–45PubMedCrossRef

74.

Atkinson JH, Slater MA, Williams RA, et al. A placebo-controlled randomized clinical trial of nortriptyline for chronic low back pain. Pain 1998; 76(3): 287–96PubMedCrossRef

75.

Sultan A, Gaskell H, Derry S, et al. Duloxetine for painful diabetic neuropathy and fibromyalgia pain: systematic review of randomised trials. BMC Neurol 2008; 8: 29PubMedCrossRef

76.

Uceyler N, Hauser W, Sommer C. A systematic review on the effectiveness of treatment with antidepressants in fibromyalgia syndrome. Arthritis Rheum 2008; 59(9): 1279–98PubMedCrossRef

77.

Carey TS, Freburger JK, Holmes GM, et al. A long way to go: practice patterns and evidence in chronic low back pain care. Spine 2009; 34(7): 718–24PubMedCrossRef

78.

van Tulder MW, Touray T, Furlan AD, et al., Cochrane Back Review Group. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration. Spine 2003; 28(17): 1978–92PubMedCrossRef

79.

Chou R, Peterson K, Helfand M. Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review. J Pain Symptom Manage 2004; 28(2): 140–75PubMedCrossRef

80.

Borenstein DG, Korn S. Efficacy of a low-dose regimen of cyclobenzaprine hydrochloride in acute skeletal muscle spasm: results of two placebo-controlled trials. Clin Ther 2003; 25(4): 1056–73PubMedCrossRef

81.

European Medicines Agency. European Medicines Agency recommends suspension of marketing authorisation for carisoprodol-containing medicinal products [online] Available from URL: http://www.emea.europa.eu/pdfs/human/press/pr/Pressrelease_Carisoprodol_52046307en.pdf [Accessed 2009 Dec 28]

82.

Berry H, Hutchinson D. Tizanidine and ibuprofen in acute low-back pain: results of a double-blind multicentre study in general practice. J Int Med Res 1988; 16(2): 83–91PubMed

83.

Corts Giner JR. Estudio DS 103-282: relajante muscular en lumbalgia aguda o lumbao (estudio doble ciego de tizanidina + paracetamol vs. placebo + paracetamol). Rev Esp de Cir Ost 1989; 24: 119–24

84.

Sirdalud Ternelin Asia-Pacific Study Group. Efficacy and gastroprotective effects of tizanidine plus diclofenac versus placebo plus diclofenac in patients with painful muscle spasms. Curr Ther Res 1998; 59: 13–22CrossRef

85.

Hingorani K. Diazepam in backache: a double-blind controlled trial. Ann Phys Med 1966; 8(8): 303–6PubMed

86.

Moll W. Zur therapie akuter lumbovertebraler syndrome durch optimale medikamentose muskelrelaxation mittels diazepam. Med Welt 1973; 24: 1747–51PubMed

87.

Arbus L, Fajadet B, Aubert D, et al. Activity of tetrazepam in low back pain. Clin Trials J 1990; 27(4): 258–67

88.

Basmajian JV. Cyclobenzaprine hydrochloride effect on skeletal muscle spasm in the lumbar region and neck: two double-blind controlled clinical and laboratory studies. Arch Phys Med Rehabil 1978; 59(2): 58–63PubMed

89.

Salzmann E, Pforringer W, Paal G, et al. Treatment of chronic low-back syndrome with tetrazepam in a placebo controlled double-blind trial. J Drug Dev 1992; 4: 219–28

90.

Muehlbacher M, Nickel MK, Kettler C, et al. Topiramate in treatment of patients with chronic low back pain: a randomized, double-blind, placebo-controlled study. Clin J Pain 2006; 22(6): 526–31PubMedCrossRef

91.

Khoromi S, Patsalides A, Parada S, et al. Topiramate in chronic lumbar radicular pain. J Pain 2005; 6(12): 829–36PubMedCrossRef

92.

McCleane GJ. Does gabapentin have an analgesic effect on background, movement and referred pain? A randomised, double-blind, placebo controlled study. Pain Clin 2001; 13(2): 103–7CrossRef

93.

Yaksi A, Ozgonenel L, Ozgonenel B. The efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Spine 2007; 32(9): 939–42PubMedCrossRef

94.

Yildirim K, Sisecioglu M, Karatay S, et al. The effectiveness of gabapentin in patients with chronic radiculopathy. Pain Clin 2003; 15(3): 213–8CrossRef

95.

Friedman BW, Holden L, Esses D, et al. Parenteral corticosteroids for emergency department patients with non-radicular low back pain. J Emerg Med 2006; 31(4): 365–70PubMedCrossRef

96.

Finckh A, Zufferey P, Schurch M, et al. Short-term efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica: a randomized controlled trial. Spine 2006; 31(4): 377–81PubMedCrossRef

97.

Haimovic IC, Beresford HR. Dexamethasone is not superior to placebo for treating lumbosacral radicular pain. Neurology 1986; 36(12): 1593–4PubMedCrossRef

98.

Porsman O, Friis H. Prolapsed lumbar disc treated with intramuscularly administered dexamethasonephosphate: a prospectively planned, double-blind, controlled clinical trial in 52 patients. Scand J Rheumatol 1979; 8(3): 142–4PubMedCrossRef

99.

Korhonen T. The treatment of disc herniation-induced sciatica with infliximab: results of a randomized, controlled, 3-month follow-up study. Spine 2005; 30(24): 2724–8PubMedCrossRef

100.

Korhonen T, Karppinen J, Paimela L, et al. The treatment of disc-herniation-induced sciatica with infliximab: one-year follow-up results of FIRST II, a randomized controlled trial. Spine 2006; 31(24): 2759–66PubMedCrossRef

101.

Katz N, Borenstein D, Birbara C, et al. Tanezumab, an anti-nerve growth factor (NGF) antibody, for the treatment of chronic low back pain (CLBP): a randomized, controlled, double-blind, phase 2 trial [abstract]. J Pain 2009; 10 (4 Suppl. 1): S42

Titel: Pharmacological Management of Low Back Pain
verfasst von: Dr Roger Chou
Publikationsdatum: 01.03.2010
Verlag: Springer International Publishing
Erschienen in: Drugs / Ausgabe 4/2010
Print ISSN: 0012-6667
Elektronische ISSN: 1179-1950
DOI: https://doi.org/10.2165/11318690-000000000-00000

Die Highlights vom Kongress des American College of Cardiology 2024

Springer Medizin

Pharmacological Management of Low Back Pain

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Die Highlights vom Kongress des American College of Cardiology 2024

Springer Medizin

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