What is the best management approach for a patient with acute on chronic back pain and radiculopathy, currently controlled with Vimovo (naproxen + esomeprazole) as needed and pregabalin, and well-controlled asthma with Symbicort (budesonide + formoterol), considering a potential switch to Celebrex (celecoxib)?

Management of Acute on Chronic Back Pain with Radiculopathy in a Patient with Asthma

For a patient with acute on chronic back pain with radiculopathy who has well-controlled asthma on Symbicort, continuing pregabalin and switching from Vimovo (naproxen + esomeprazole) to celecoxib is an appropriate management strategy.

Current Medication Assessment

• The patient is currently on:

  • Vimovo (naproxen + esomeprazole) PRN for pain
  • Pregabalin for radiculopathy
  • Symbicort (budesonide + formoterol) for asthma control

• Pregabalin is showing efficacy without side effects, which is important as evidence for pregabalin in radicular pain shows small to moderate benefits 1

• NSAIDs like naproxen (component of Vimovo) are recommended as first-line treatment for radiculopathy due to their moderate efficacy in targeting the inflammatory component of radicular pain 1

Evidence-Based Medication Recommendations

Continue Pregabalin

• Pregabalin has demonstrated efficacy for neuropathic pain components of radiculopathy, though evidence shows inconsistent results with effects on pain intensity ranging from 0.3 to 1.9 points on a 0-10 point scale 2, 1
• Since the patient is tolerating pregabalin without side effects, continuing this medication is appropriate as it addresses the neuropathic component of radiculopathy 1, 3
• Pregabalin can improve both pain and function in patients with chronic low back pain with radiculopathy, with significant reduction in neuropathic pain scores by the 4th and 12th weeks of treatment 3

NSAID Selection: Celecoxib vs. Naproxen

• Switching from Vimovo (naproxen + esomeprazole) to celecoxib is reasonable, especially in a patient with asthma 4
• Celecoxib (COX-2 selective inhibitor) has a lower risk of bronchospasm in patients with asthma compared to non-selective NSAIDs like naproxen 4
• Both naproxen and celecoxib have demonstrated efficacy for back pain, though newer trials report that NSAIDs had smaller benefits for chronic low back pain than previously observed 2

Special Considerations for Asthma

• Non-selective NSAIDs like naproxen can potentially exacerbate asthma in sensitive individuals, making celecoxib a safer alternative 4
• The patient's asthma is well-controlled on Symbicort, which should be continued without interruption 4
• Celecoxib has a better safety profile regarding respiratory symptoms in patients with asthma due to its COX-2 selectivity 4

Potential Pitfalls and Monitoring

• Monitor for gastrointestinal and cardiovascular side effects with celecoxib, using the lowest effective dose 1
• While pregabalin is effective for neuropathic pain, be aware that it may affect balance, particularly during initial dosing and dose increases 3
• Avoid systemic corticosteroids for back pain with radiculopathy as they have consistently shown no benefit for pain relief in multiple trials 2
• Regularly assess the continued need for pregabalin, as extended courses should be reserved for patients showing clear ongoing benefits 1

Treatment Algorithm

1. Switch from Vimovo to celecoxib for the inflammatory component of pain, which is safer for patients with asthma 4
2. Continue pregabalin at the current effective dose for the neuropathic component of radiculopathy 1, 3
3. Maintain Symbicort for asthma control 4
4. Consider adding duloxetine if pain control remains inadequate, as it has shown small but consistent benefits for chronic low back pain (differences of 0.60 to 0.79 points on the Brief Pain Inventory severity scale) 2
5. Avoid benzodiazepines for radiculopathy as they may worsen pain compared to placebo 2