What medications are recommended for left side sciatica?

Medication Management for Left-Sided Sciatica

For left-sided sciatica, start with NSAIDs as first-line therapy, then add gabapentin if pain persists after 1-2 weeks, targeting both the inflammatory and neuropathic pain components. 1, 2

First-Line Treatment: NSAIDs

• NSAIDs are the recommended initial pharmacological treatment for sciatica, with evidence showing a risk ratio of 1.14 (95% CI 1.03-1.27) for global improvement versus placebo 2, 3
• Specific dosing options include:
  • Naproxen 500 mg twice daily 2
  • Ibuprofen 400-800 mg three times daily 2
  • Meloxicam 7.5-15 mg once daily (COX-2 selective with fewer GI side effects) 2, 4
• Allow at least 8 weeks for full NSAID effect, as the time course to response is approximately 1 month 2
• Continuous NSAID treatment is preferred over on-demand dosing for inflammatory conditions like sciatica 2, 4

NSAID Selection Based on Risk Profile

• For patients with GI risk factors (age >65, history of ulcers, concurrent corticosteroids): use COX-2 selective NSAIDs like meloxicam or add gastroprotective agents 5, 4
• For patients with cardiovascular risk factors: carefully weigh risks, as both traditional NSAIDs and COX-2 inhibitors carry cardiovascular toxicity concerns 5, 4
• Monitor for GI bleeding, cardiovascular events, and renal dysfunction, especially with long-term use 2, 4

Second-Line: Add Gabapentin for Neuropathic Component

If NSAIDs alone provide inadequate relief after 1-2 weeks, add gabapentin to target the neuropathic pain component of sciatica. 1, 2

• Gabapentin shows small to moderate short-term benefits specifically for radicular pain/sciatica 1, 2, 6
• Dosing: Start at 300 mg at bedtime, titrate up to 1200-3600 mg/day divided into three doses (e.g., 300-1200 mg three times daily) 1, 6
• Sciatica is a mixed pain syndrome with both nociceptive (inflammatory) and neuropathic components, explaining why combination therapy targeting both mechanisms is often necessary 7
• Monitor for sedation, dizziness, and peripheral edema; adjust dosing in renal impairment 1, 2

Why Gabapentin Works for Sciatica

• Gabapentin prevents central sensitization and addresses nerve root compression pain that NSAIDs cannot adequately treat 7, 6
• Case reports demonstrate rapid pain improvement, sometimes after the first dose, with complete resolution possible over several weeks 6

Third-Line: Tricyclic Antidepressants

If the combination of NSAIDs plus gabapentin is insufficient, add amitriptyline. 1, 2

• Amitriptyline provides moderate pain relief for chronic low back pain with good evidence supporting efficacy 1, 2
• Dosing: Start at 10-25 mg at bedtime, titrate by 10-25 mg weekly as tolerated to target dose of 50-75 mg at bedtime 2
• Amitriptyline blocks sodium channels and inhibits serotonin/norepinephrine reuptake, addressing neuropathic pain through different mechanisms than gabapentin 7

Adjunctive Therapy for Acute Severe Pain

For acute exacerbations with severe pain, consider short-term muscle relaxants (≤2-3 weeks only). 1, 2

• Cyclobenzaprine 5-10 mg three times daily has the strongest evidence among muscle relaxants 1, 2
• Tizanidine 2-4 mg three times daily (can increase to 8 mg three times daily) may be combined with NSAIDs for enhanced pain relief, though this increases CNS adverse events 1, 2
• Critical limitation: No evidence supports muscle relaxant use beyond 2 weeks; avoid in chronic sciatica 1
• Avoid in elderly patients due to fall risk and cognitive impairment from sedation 1

Medications to AVOID

Systemic Corticosteroids: NOT Recommended

Do not use systemic corticosteroids for sciatica—they are ineffective. 5, 1, 2

• Three higher-quality trials consistently found no clinically significant benefit compared to placebo when given parenterally or as short oral tapers 5, 2
• This applies to both acute sciatica and sciatica of unspecified duration 5

Opioids: Avoid

Opioids should be avoided due to limited evidence for short-term modest effects with significant risks including constipation, sedation, nausea, and potential for abuse/addiction 1, 2

• While one study showed morphine superior to acetaminophen at 30 minutes, the long-term risk-benefit ratio does not support routine use 8

Benzodiazepines: Ineffective

Benzodiazepines are ineffective for radiculopathy based on low-quality evidence and carry risks of abuse, addiction, and tolerance 1, 2

Clinical Algorithm Summary

1. Start with NSAID monotherapy (naproxen, ibuprofen, or meloxicam based on GI/CV risk profile) 2, 4
2. After 1-2 weeks, if inadequate response: Add gabapentin 300 mg at bedtime, titrate to effect 1, 2
3. After 4-6 weeks, if still inadequate: Add amitriptyline 10-25 mg at bedtime, titrate weekly 1, 2
4. For acute severe exacerbations only: Consider cyclobenzaprine for ≤2-3 weeks 1, 2
5. Reassess efficacy and side effects regularly; discontinue ineffective medications 1

Key Pitfalls to Avoid

• Do not prescribe muscle relaxants for chronic sciatica—no evidence beyond 2 weeks 1
• Do not use systemic corticosteroids—they are ineffective despite common practice 5, 2
• Do not rely on NSAIDs alone for severe radicular pain—the neuropathic component requires gabapentin or tricyclic antidepressants 1, 7
• Do not forget to monitor renal function with NSAIDs and adjust gabapentin dosing in renal impairment 2, 4