Is eperisone effective for treating lumbar pain?

Eperisone for Lumbar Pain

Eperisone is not recommended as a first-line treatment for lumbar pain based on major clinical practice guidelines, which instead prioritize NSAIDs and acetaminophen; however, eperisone may be considered as an alternative skeletal muscle relaxant when first-line therapies fail, particularly in acute low back pain with muscle spasm.

Guideline-Based Treatment Hierarchy

First-Line Therapy

• NSAIDs are the preferred initial medication for acute low back pain, providing small to moderate improvements in pain intensity 1
• Acetaminophen serves as an alternative first-line option due to favorable safety profile, though evidence shows no significant difference from placebo 1
• Patients should remain active and avoid bed rest, as activity restriction prolongs recovery 1

Second-Line Therapy: Skeletal Muscle Relaxants

• Skeletal muscle relaxants (as a class) are moderately superior to placebo for short-term pain relief in acute low back pain, with relative risks for not achieving pain relief of 0.80 (CI, 0.71 to 0.89) at 2-4 days 2
• Major guidelines found insufficient evidence to conclude that any specific muscle relaxant is superior to others for benefits or harms 2
• All skeletal muscle relaxants carry central nervous system adverse effects, primarily sedation 1

Eperisone-Specific Evidence

Efficacy Data

• A randomized, double-blind, placebo-controlled trial (n=240) demonstrated eperisone 150 mg/day significantly improved finger-to-floor distance (150.66 to 41.75 cm) compared to placebo (138.51 to 101.60 cm, P<0.001) over 14 days 3
• Therapy was rated as good-excellent in 79.46% of eperisone patients versus 38.05% of placebo patients 3
• A 2020 prospective study showed combination therapy (eperisone + ibuprofen) achieved clinically significant pain reduction (>50% from baseline) in 72.4% of patients versus 46.7% with ibuprofen alone at 4 weeks 4
• A systematic review of 7 studies (801 participants) found eperisone may be effective in acute low back pain with less adverse effects (relative risk, 0.25; 95% CI, 0.15-0.41; P<0.0001) 5

Safety Profile

• Eperisone's key advantage is the absence of CNS sedative effects that characterize other muscle relaxants 6, 7
• Only 5% of eperisone-treated patients experienced minor gastrointestinal side effects compared to 21.25% with thiocolchicoside 7
• Common adverse events include nausea, abdominal pain, headache, and dizziness 3

Clinical Decision Algorithm

For Acute Low Back Pain:

1. Start with NSAIDs (lowest effective dose, shortest duration) + activity maintenance 1
2. If NSAIDs contraindicated or insufficient after 2-4 days, add skeletal muscle relaxant 2, 1
3. Eperisone 50 mg three times daily can be selected when CNS sedation must be avoided (e.g., patients who drive, operate machinery, or are elderly) 6, 3
4. Reassess at 3 days and continue up to 10-14 days if improving 6, 3

For Chronic Low Back Pain:

• Evidence for skeletal muscle relaxants (including eperisone) in chronic low back pain is sparse and of lower quality 2
• Only one lower-quality trial evaluated a muscle relaxant for chronic low back pain in the major guideline review 2

Critical Limitations and Caveats

Evidence Quality Issues

• The systematic review concluded that included studies are of smaller sample size and short duration to definitively support eperisone use, recommending larger, longer trials 5
• Major American and international guidelines do not specifically mention eperisone, as it is not FDA-approved in the United States 2, 1
• Most eperisone trials were conducted in Asia and Europe, limiting generalizability 6, 3, 7

Practical Considerations

• Eperisone's mechanism differs from other muscle relaxants: it inhibits spinal reflexes AND regulates blood supply to skeletal muscles, potentially addressing ischemia-induced nociception 6
• The drug may be particularly useful when muscle contracture is the primary pain generator 6
• Rescue medication was still needed by 35.71% of eperisone patients versus 73.45% of placebo patients, indicating incomplete pain control in many cases 3

What NOT to Do

• Do not use eperisone as first-line therapy before trying NSAIDs or acetaminophen 1
• Do not prescribe extended courses without clear evidence of continued benefits 1
• Do not assume eperisone is superior to other muscle relaxants based on current evidence, as head-to-head trials show comparable efficacy 7
• Avoid combining with benzodiazepines, which carry abuse and addiction risks 1