What is the best treatment approach for a backache that responds to corticosteroids (Non-Steroidal Anti-Inflammatory Drugs, NSAIDs)?

Treatment Approach for Backache Responding to Corticosteroids

NSAIDs are recommended as first-line treatment for backache that responds to corticosteroids, rather than systemic corticosteroids themselves, which show limited efficacy for non-radicular back pain. 1

First-Line Treatment Options

NSAIDs

• Moderate-quality evidence shows NSAIDs provide small to moderate pain improvement compared to placebo for both acute and chronic low back pain 1, 2, 3
• For acute low back pain: NSAIDs provide short-term pain reduction (mean difference -7.29 on a 0-100 VAS scale) and improved disability (mean difference -2.02 on the Roland Morris Disability Questionnaire) 2
• For chronic low back pain: NSAIDs show a small but significant effect (mean difference -3.30 on a 0-100 VAS scale) 3
• No significant differences between different types of NSAIDs, including between COX-2 selective and non-selective NSAIDs 1
• Limit NSAID use to one week with monitoring of gastrointestinal, renal, and cardiovascular side effects 4

Skeletal Muscle Relaxants (SMRs)

• Moderate-quality evidence shows SMRs improve short-term pain relief compared with placebo after 2-7 days 1
• Consider adding to NSAIDs for acute back pain with muscle spasm
• Low-quality evidence shows inconsistent findings for combining SMRs with NSAIDs versus NSAIDs alone 1

Second-Line Options

Acetaminophen

• Can be used for pain control, especially when NSAIDs are contraindicated 4
• One trial showed no difference between diflunisal (an NSAID) and paracetamol for pain intensity 3

Antidepressants

• For chronic back pain with neuropathic component:
  • Duloxetine shows moderate-quality evidence for small improvements in pain intensity and function compared to placebo 1
  • TCAs and SSRIs show no significant difference in pain compared to placebo (moderate-quality evidence) 1

Physical Therapy and Non-Pharmacological Approaches

• Strongly recommended over no treatment, focusing on active interventions (supervised exercise) rather than passive interventions 4
• Low-quality evidence showed that massage moderately improved short-term pain and function compared with sham therapy for subacute back pain 1
• Heat therapy: Moderate-quality evidence showed that a heat wrap moderately improved pain relief and disability compared with placebo 1

Corticosteroids for Back Pain

Despite the question's premise about backache responding to corticosteroids, the evidence does not support their use:

• Low-quality evidence showed no difference in pain or function between systemic corticosteroids and placebo for acute low back pain 1, 5
• For radicular low back pain (sciatica), moderate-quality evidence indicates systemic corticosteroids probably slightly decrease pain versus placebo at short-term follow-up, but the effect is small (MD 0.56 points better on a 0-10 scale) 5
• A randomized controlled trial found no benefit from oral prednisone in emergency department patients with musculoskeletal low back pain 6

Treatment Algorithm

1. Initial treatment (0-2 weeks):

   • NSAIDs for up to one week (e.g., ibuprofen 400-600mg TID or naproxen 500mg BID)
   • Consider adding SMR for muscle spasm (e.g., cyclobenzaprine 5-10mg TID)
   • Heat therapy
   • Encourage continued activity as tolerated

2. If inadequate response after 1-2 weeks:

   • Consider physical therapy with focus on active exercises
   • For persistent pain with neuropathic features, consider duloxetine (30-60mg daily)

3. For radicular pain component:

   • If radicular symptoms predominate and are severe, a short course of systemic corticosteroids may provide slight benefit
   • Consider gabapentin or pregabalin for neuropathic component 4

Common Pitfalls to Avoid

1. Overuse of corticosteroids: Despite the question's premise, systemic corticosteroids have limited evidence for non-radicular back pain and should not be first-line therapy 1, 5

2. Prolonged NSAID use: Limit to one week when possible to avoid gastrointestinal, renal, and cardiovascular adverse effects 4

3. Overreliance on passive therapies: Focus on active interventions rather than solely passive treatments like massage or ultrasound 4

4. Opioid prescribing: Opioids should only be prescribed as a last resort and for very limited duration 4

5. Premature imaging: Imaging is not necessary for most cases of acute or subacute back pain without red flags 4

By following this evidence-based approach, most patients with backache should experience significant improvement while minimizing medication-related adverse effects.