What are the pharmacological management options for lumbar (lower back) pain?

From the Guidelines

Pharmacological management of lumbar (lower back) pain should start with nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg three times daily) or naproxen (250-500mg twice daily) for short courses of 1-2 weeks to reduce inflammation and pain, as recommended by the most recent and highest quality study 1.

Key Considerations

• For mild pain, acetaminophen (Tylenol) at 500-1000mg every 6 hours (maximum 4g daily) may be considered, although its effectiveness for acute low back pain has been questioned in recent studies 1.
• Muscle relaxants such as cyclobenzaprine (5-10mg three times daily) or baclofen (5-20mg three times daily) may be added for up to 1-2 weeks when muscle spasms are present.
• For severe pain, short-term opioid use might be considered, such as tramadol (50-100mg every 4-6 hours) or hydrocodone/acetaminophen (5/325mg every 4-6 hours) for 3-7 days maximum, but with caution due to the risks of dependence and addiction.
• Topical treatments like diclofenac gel (1% applied four times daily) can provide localized relief with fewer systemic side effects.

Important Factors to Consider

• Patients with kidney disease, heart conditions, or gastrointestinal disorders should use NSAIDs cautiously, and elderly patients generally require lower doses of all medications.
• The benefits and harms of each medication class should be carefully weighed, and individual patients may differ in how they weigh potential benefits, harms, and costs of various medications.
• The use of medications should be part of a comprehensive management plan that includes non-pharmacologic therapies, such as exercise, physical therapy, and lifestyle modifications.

From the FDA Drug Label

NSAID medicines are used to treat pain and redness, swelling, and heat (inflammation) from medical conditions such as: different types of arthritis menstrual cramps and other types of short-term pain The efficacy of pregabalin for the management of neuropathic pain associated with spinal cord injury was established in two double-blind, placebo-controlled, multicenter studies

The pharmacological management options for lumbar (lower back) pain include:

• NSAIDs (e.g. naproxen) to treat pain and inflammation
• Pregabalin for the management of neuropathic pain associated with spinal cord injury, which may be relevant to some cases of lumbar pain 2 Note that the FDA label for pregabalin does not directly address lumbar pain, but rather neuropathic pain associated with spinal cord injury 2 and fibromyalgia. Naproxen's label does not specifically mention lumbar pain, but NSAIDs are commonly used to treat various types of pain, including lower back pain 3

From the Research

Pharmacological Management Options for Lumbar (Lower Back) Pain

The following are pharmacological management options for lumbar (lower back) pain:

• Paracetamol (acetaminophen) and NSAIDs are first-line options for pain relief in most patients with low back pain, regardless of the duration of symptoms 4
• Opioids are more potent analgesics, but are not a first-line option due to their abuse potential 4
• Skeletal muscle relaxants and benzodiazepines can be used as adjunctive medications for acute low back pain, but have a high incidence of sedation 4
• Tricyclic antidepressants may be an option for chronic low back pain, but their effects on pain appear small or uncertain 4
• NSAIDs have been shown to be effective in reducing pain intensity and disability in acute and chronic low back pain, with moderate to high certainty of evidence 5, 6
• Muscle relaxants have been shown to be effective in reducing pain intensity and improving physical function in acute low back pain, with moderate certainty of evidence 5
• Opioids have been shown to be effective in reducing pain intensity in chronic low back pain, but with low to moderate certainty of evidence and an increased risk of adverse events 5, 7
• Antidepressants have been shown to have no significant effect on pain intensity or disability in chronic low back pain, with low certainty of evidence 5, 7

Medication Comparison

Comparison of different medications for low back pain:

• NSAIDs vs. paracetamol: NSAIDs have been shown to be more effective than paracetamol in reducing pain intensity and disability in acute and chronic low back pain 5, 6
• NSAIDs vs. muscle relaxants: NSAIDs have been shown to be more effective than muscle relaxants in reducing pain intensity and disability in acute and chronic low back pain, but with a higher risk of adverse events 5, 6
• Opioids vs. NSAIDs: Opioids have been shown to be more effective than NSAIDs in reducing pain intensity in chronic low back pain, but with a higher risk of adverse events and lower certainty of evidence 5, 7

Treatment Guidelines

Treatment guidelines for low back pain:

• The American Pain Society and the American College of Physicians recommend paracetamol and NSAIDs as first-line options for pain relief in most patients with low back pain, regardless of the duration of symptoms 4
• The Cochrane Database of Systematic Reviews recommends NSAIDs and muscle relaxants as effective treatments for acute and chronic low back pain, but with varying levels of certainty of evidence 5, 6