In the Literature

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

Summary published May 31, 2023

Summary by Heather Columbano, MD

British Medical Journal | March 2023

Wewege MA, Bagg MK, Jones MD, Ferraro MC, Cashin AG, Rizzo RR, Leake HB, Hagstrom AD, Sharma S, McLachlan AJ, Maher CG, Day R, Wand BM, O'Connell NE, Nikolakopolou A, Schabrun S, Gustin SM, McAuley JH. Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain: systematic review and network meta-analysis. BMJ. 2023 Mar 22;380:e072962. doi: 10.1136/bmj-2022-072962. PMID: 36948512.

doi: https://doi.org/10.1136/bmj-2022-072962

  • This systematic review and network meta-analysis aimed to compare the effectiveness and safety of various analgesic medicines and combinations for acute non-specific low back pain. Primary outcomes were low back pain intensity (0-100 scale) at end of treatment and safety (adverse events during treatment). Secondary outcomes were low back specific function and discontinuation from treatment.
  • The meta-analysis included 98 randomized controlled trials (15,134 participants, 49% women). The trials included adults aged 18 years and above who reported acute non-specific low back pain lasting less than six weeks. The study compared the efficacy 69 different analgesic medications, including non-steroidal anti-inflammatory drugs, paracetamol, opioids, anti-convulsant drugs, skeletal muscle relaxants, or corticosteroids, compared with other analgesics, placebo, or no treatment.
  • The findings of this study indicated low or very low confidence in the evidence supporting reduced pain intensity with tolperisone (mean difference −26.1, 95% confidence intervals −34.0 to −18.2), aceclofenac plus tizanidine (−26.1, −38.5 to −13.6), pregabalin (−24.7, −34.6 to −14.7), and 14 other medicines compared with placebo. The occurrence of adverse events showed moderate to very low confidence with tramadol (risk ratio 2.6, 95% confidence interval 1.5 to 4.5), paracetamol plus sustained release tramadol (2.4, 1.5 to 3.8), baclofen (2.3, 1.5 to 3.4), and paracetamol plus tramadol (2.1, 1.3 to 3.4) compared to placebo.
  • This meta-analysis highlights the heterogeneity in the utilization of analgesic medications and combinations for acute non-specific low back pain. Due to the limited consensus regarding the choice and use of analgesic medications for this condition, further high-quality, direct 1:1 controlled trials are necessary to enhance patient safety and efficacy. Consequently, a cautious approach to analgesic medication management is recommended for acute non-specific low back pain at present.