What are the recommended medications for backache?

Recommended Medications for Backache

First-Line Treatment: NSAIDs and Acetaminophen

For both acute and chronic low back pain, NSAIDs are the most strongly recommended first-line pharmacological treatment, with good evidence demonstrating moderate pain relief (10-20 points on a 100-point scale). 1

NSAIDs (Preferred First-Line)

• NSAIDs like ibuprofen show superior efficacy to placebo for global improvement (RR 1.24) and reduced need for additional analgesics (RR 1.29) after 1 week of therapy in acute low back pain. 1
• For chronic low back pain, ibuprofen demonstrates effectiveness superior to placebo in high-quality trials. 1
• No specific NSAID has proven superior to others for pain relief, so choose based on cost and patient-specific risk factors. 1
• Use NSAIDs at the lowest effective dose for the shortest duration necessary due to risks of gastrointestinal bleeding, cardiovascular events, and renal complications. 2, 3
• In elderly patients, carefully assess cardiovascular, gastrointestinal, and renal risk factors before prescribing NSAIDs. 2

Acetaminophen (Alternative First-Line)

• Acetaminophen up to 4g/24 hours is recommended as first-line treatment, particularly in elderly patients, due to its favorable safety profile. 2
• Evidence shows acetaminophen is slightly inferior to NSAIDs for pain relief (standardized mean difference ~0.3), but the difference is modest. 1
• Monitor for hepatotoxicity, especially at maximum doses. 2
• For acute low back pain, no significant difference exists between acetaminophen (3g/day) and no treatment in one trial. 1

Second-Line Treatment: Skeletal Muscle Relaxants

For acute low back pain requiring additional relief beyond NSAIDs, skeletal muscle relaxants are effective for short-term pain relief, with good supporting evidence. 1

Cyclobenzaprine (Preferred Muscle Relaxant)

• Cyclobenzaprine 5mg three times daily demonstrates statistically significant superiority over placebo for pain relief, global improvement, and medication helpfulness at day 8. 4
• Start with 5mg doses in elderly patients and those with hepatic impairment, titrating slowly upward. 4
• Common side effects include drowsiness and dry mouth; use time-limited courses due to sedation risk. 4
• Cyclobenzaprine produces clinical improvement whether or not sedation occurs. 4

Tizanidine (Alternative Muscle Relaxant)

• Tizanidine is considered more effective than baclofen for lumbar radiculopathy with a better safety profile. 5
• The American College of Physicians does not recommend baclofen as a preferred muscle relaxant option. 5

Third-Line Treatment: Tricyclic Antidepressants for Chronic Pain

For chronic low back pain, tricyclic antidepressants show small to moderate effects for pain relief (effect size 0.5-0.8). 1, 5

• Tricyclic antidepressants have good evidence for effectiveness specifically in chronic (not acute) low back pain. 1
• The magnitude of benefit is smaller than NSAIDs or muscle relaxants but may be appropriate for patients with concurrent depression. 1

Specialized Treatment: Gabapentin for Radiculopathy

For low back pain with radiculopathy (sciatica), gabapentin demonstrates small, short-term benefits specifically for radicular symptoms. 1, 5

• Gabapentin has fair evidence for effectiveness in patients with nerve root involvement. 1
• Consider gabapentin when radicular symptoms predominate over axial back pain. 5

Fourth-Line Treatment: Opioids (Use Judiciously)

Opioid analgesics or tramadol may be considered only for severe, disabling pain not controlled with acetaminophen and NSAIDs, with careful weighing of substantial risks including abuse potential. 2

• Prescribe opioids only for breakthrough pain, at the lowest effective dose, for the shortest period. 2
• Combination hydrocodone/ibuprofen and oxycodone/acetaminophen show similar efficacy and tolerability for moderate to severe acute low back pain. 6
• Opioids are not first-line due to abuse potential despite being more potent analgesics. 7

Treatments NOT Recommended

Systemic corticosteroids have good evidence of ineffectiveness for low back pain with or without sciatica and should not be used. 1, 5

• Baclofen is not recommended as a preferred muscle relaxant option. 5
• Bed rest is ineffective based on low-quality evidence. 8

Treatment Algorithm

1. Start with NSAIDs (ibuprofen 200-400mg every 4-6 hours, max 5 tablets/day) or acetaminophen (up to 4g/24 hours) for all patients with acute or chronic low back pain. 1, 2, 3

2. If inadequate relief after 3-7 days, add cyclobenzaprine 5mg three times daily for acute low back pain (time-limited course). 5, 4

3. For chronic low back pain not responding to NSAIDs alone, consider tricyclic antidepressants rather than adding muscle relaxants. 1, 5

4. For radiculopathy symptoms (leg pain, numbness, tingling), add gabapentin to the regimen. 1, 5

5. Reserve opioids only for severe, disabling pain unresponsive to the above measures, using the shortest duration and lowest dose. 2

Critical Pitfalls to Avoid

• Never prescribe systemic corticosteroids for low back pain—they are proven ineffective. 1, 5
• Avoid long-term muscle relaxant use; prescribe for fixed, time-limited periods only due to sedation and limited long-term safety data. 5
• Do not use baclofen when tizanidine or cyclobenzaprine are available. 5
• In elderly patients, avoid starting NSAIDs without assessing cardiovascular, renal, and gastrointestinal risk factors. 2
• Most trials evaluate only short-term therapy (≤4 weeks); reliable data on long-term benefits and harms are sparse. 1
• Combination therapy data are limited; most evidence supports monotherapy with sequential additions if needed. 1