What are the recommended medications and treatments for a patient with back pain, considering their medical history and potential allergies or sensitivities?

Recommended Medications for Back Pain

NSAIDs are the first-line medication for back pain, providing moderate pain relief with the best evidence for efficacy, and should be prescribed at the lowest effective dose for the shortest necessary duration. 1, 2

Acute Back Pain (<12 weeks)

First-Line Pharmacologic Treatment

• NSAIDs (ibuprofen, naproxen, celecoxib) provide small to moderate improvements in pain intensity and are the preferred initial medication based on good evidence from randomized controlled trials. 1, 2
• Assess cardiovascular and gastrointestinal risk factors before prescribing any NSAID, as cardiovascular risk increases with longer use and higher doses. 2, 3
• Celecoxib may be preferred in patients with gastrointestinal risk factors, as it decreased mean 24-hour systolic blood pressure by 0.3 mmHg compared to increases of 3.7 mmHg with ibuprofen and 1.6 mmHg with naproxen. 4
• Acetaminophen can be considered as an alternative first-line option due to favorable safety profile, though it shows no significant difference from placebo for pain intensity or function. 2

Second-Line Options for Severe Pain

• Skeletal muscle relaxants (cyclobenzaprine, methocarbamol) improve short-term pain relief after 2-7 days when severe pain persists despite adequate NSAID dosing. 1, 2
• Prescribe muscle relaxants for time-limited courses only (≤1-2 weeks), as no evidence supports efficacy beyond 2 weeks. 5
• All skeletal muscle relaxants cause central nervous system adverse effects, primarily sedation, which is dose-related but independent of efficacy. 1, 5
• Cyclobenzaprine has the largest body of evidence with pooled data from 20 trials (n=1553) showing superiority to placebo for short-term global improvement. 5

Critical Non-Pharmacologic Measures

• Advise patients to remain active and avoid bed rest, as activity restriction prolongs recovery and delays return to normal activities. 2, 3
• Application of superficial heat via heating pads provides short-term symptomatic relief and should be recommended alongside NSAIDs. 2, 3

Medications to Avoid in Acute Back Pain

• Systemic corticosteroids are not recommended, as they have not been shown more effective than placebo for acute low back pain with or without sciatica. 1, 2
• Benzodiazepines show similar effectiveness to skeletal muscle relaxants but carry risks for abuse, addiction, and tolerance; avoid unless absolutely necessary. 1, 2
• Insufficient evidence exists to recommend antidepressants or antiseizure medications for acute low back pain. 2

Chronic Back Pain (≥12 weeks)

First-Line Pharmacologic Treatment

• NSAIDs remain the initial medication of choice with moderate short-term efficacy for pain relief in chronic low back pain. 1, 5
• Use at the lowest effective dose for the shortest necessary period, with ongoing reassessment of cardiovascular and gastrointestinal risk factors. 5

Second-Line Options

• Tricyclic antidepressants (amitriptyline, nortriptyline) provide moderate pain relief for chronic low back pain and should be added when NSAIDs alone are insufficient. 1, 5
• Duloxetine is associated with small improvements in pain intensity and function compared to placebo (moderate-quality evidence) and is particularly useful if chronic pain is accompanied by depression. 5, 6
• Selective serotonin reuptake inhibitors (SSRIs) may be considered specifically for patients with diabetic neuropathy but have limited evidence for nonspecific chronic back pain. 1

For Radicular Pain/Sciatica

• Gabapentin shows small to moderate short-term benefits specifically for radicular pain, with doses titrated up to 1200-3600 mg/day in divided doses. 5
• Start with 300 mg three times daily and increase to therapeutic doses of 1200-3600 mg/day, as lower doses are subtherapeutic. 5
• Monitor patients on gabapentin for sedation, dizziness, and peripheral edema, and adjust dosing in patients with renal impairment. 5
• Pregabalin shows no benefit for chronic nonradicular back pain and may actually worsen function. 5

Opioid Considerations

• Extended-release oral opioids may be used as part of a multimodal strategy for neuropathic or back pain patients when other treatments have failed. 1
• Opioids have limited evidence for short-term modest effects on chronic low back pain and are associated with nausea, dizziness, constipation, vomiting, somnolence, and dry mouth. 5
• Substantial risks include aberrant drug-related behaviors, abuse potential, and addiction, requiring careful weighing of benefits and harms before initiating therapy. 2
• A time-limited trial of tramadol can be considered if pain remains uncontrolled, avoiding stronger opioids due to substantial abuse risks and limited long-term efficacy. 5

Medications to Avoid in Chronic Back Pain

• Do not prescribe skeletal muscle relaxants for chronic low back pain, as no evidence supports efficacy beyond 2 weeks. 5
• Benzodiazepines are ineffective for radiculopathy based on low-quality evidence and should be avoided due to risks of abuse and tolerance. 5
• Systemic corticosteroids are not recommended for chronic low back pain with or without sciatica. 1, 5

Algorithmic Treatment Approach

For Acute Back Pain:

1. Start with NSAID (ibuprofen 400-800 mg TID, naproxen 500 mg BID, or celecoxib 200 mg daily) after assessing CV/GI risk. 1, 2
2. Add superficial heat and advise remaining active. 2, 3
3. If severe pain persists after 2-4 days, add short-term muscle relaxant (cyclobenzaprine 5-10 mg TID for ≤1-2 weeks). 5, 2
4. Reassess at 1 month; most patients experience substantial improvement within the first month. 3

For Chronic Back Pain Without Radiculopathy:

1. Start with NSAID at lowest effective dose. 5
2. If insufficient response after 2-4 weeks, add tricyclic antidepressant (amitriptyline 10-25 mg at bedtime, titrate to 50-75 mg) or duloxetine 30-60 mg daily. 5, 6
3. Reassess efficacy and side effects regularly. 5
4. Consider time-limited tramadol trial if pain remains uncontrolled. 5

For Chronic Back Pain With Radiculopathy:

1. Start with NSAID to target inflammatory component. 5
2. Add gabapentin 300 mg TID, titrate to 1200-3600 mg/day for neuropathic component. 5
3. If insufficient response, add tricyclic antidepressant or duloxetine. 5
4. For acute exacerbations, consider short-term skeletal muscle relaxant. 5
5. Failure to respond within 4-6 weeks warrants specialist referral for consideration of epidural steroid injections or surgical evaluation. 5

Critical Pitfalls to Avoid

• Never prescribe bed rest or activity restriction—this provides no benefit and delays recovery. 2, 3
• Do not use extended courses of medications without clear evidence of continued benefits and absence of major adverse events. 2
• Do not prescribe muscle relaxants for chronic low back pain or beyond 2 weeks for acute pain. 5
• Do not use gabapentin at subtherapeutic doses (300 mg TID is insufficient for radicular pain). 5
• Monitor for hepatotoxicity when using acetaminophen at maximum doses, especially in elderly patients or those with hepatic impairment. 2
• Patients on celecoxib and concomitant low-dose aspirin experience 4-fold higher rates of complicated ulcers compared to those not on aspirin. 4