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NSAIDs offer little benefit for spinal pain, review finds

BMJ 2017; 356 doi: (Published 06 February 2017) Cite this as: BMJ 2017;356:j605
  1. Anne Gulland
  1. London

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen offer little more clinical benefit to patients with spinal pain than a placebo, a systematic review and meta-analysis has found.

The review of 35 randomised placebo controlled trials involving 6065 people, published in the Annals of the Rheumatic Diseases,1 found that NSAIDs did provide some relief from pain and disability but found little evidence that they were more effective than placebo. Researchers found that, in every six patients treated with an NSAID, only one would benefit.

Pooling all of the trials revealed moderate quality evidence that NSAIDs reduced pain in the immediate and short term when compared with placebo. But high quality evidence was found of clinically unimportant effects of NSAIDs when compared with placebo.

The researchers also found that patients taking NSAIDs were more likely to experience side effects. Patients given NSAIDs were two and a half times more likely to suffer gastrointestinal events than those taking a placebo (relative risk 2.5 (95% confidence interval 1.2 to 5.2)). Of 702 patients taking NSAIDs 28 had gastrointestinal adverse reactions, compared with nine of 465 in the placebo group.

The authors said that their findings were significant because spinal pain is the leading cause of disability worldwide and is commonly managed in general practice by prescription medicines. Clinical guidelines generally recommend NSAIDs as a second line analgesic after paracetamol; however, recent studies have shown paracetamol to be ineffective. The third line treatment is opioid medicine, but this too has been shown to offer little benefit.

The researchers wrote, “In our review, even when the effects of NSAIDs were analysed for different spinal pain strata (i.e. neck pain, acute/chronic low back pain or sciatica) only three of the 14 analyses revealed effects that were marginally above our threshold for clinical relevance.”

Gustavo Machado, research fellow at the George Institute and the School of Medicine at the University of Sydney, Australia, said, “Millions of Australians are taking drugs that not only don’t work very well, they’re causing harm. We need treatments that will actually provide substantial relief of these people’s symptoms.

“Better still, we need a stronger focus on preventing back pain in the first place. We know that education and exercise programmes can substantially reduce the risk of developing low back pain.”

The paper concluded that new analgesics for spinal pain are urgently needed.


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