What are the pharmaceutical therapy options for chronic lumbar (lower back) strain?

From the Guidelines

Pharmaceutical therapy for chronic lumbar strain should begin with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks to reduce inflammation and pain, as recommended by the American College of Physicians and the American Pain Society 1.

Key Considerations

• For patients who cannot tolerate NSAIDs or have contraindications like kidney disease or gastric ulcers, acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) is an alternative, though it's less effective for inflammatory pain 1.
• If pain persists, muscle relaxants such as cyclobenzaprine (5-10mg three times daily) or baclofen (10-20mg three times daily) may be prescribed for short-term use (1-2 weeks) to reduce muscle spasms 1.
• For more severe pain, tramadol (50-100mg every 4-6 hours) might be considered, but opioids should generally be avoided due to risk of dependence 1.
• Topical treatments like diclofenac gel (1% applied to the affected area 3-4 times daily) can provide localized relief with fewer systemic side effects.

Comprehensive Management

• It's essential to combine medication with physical therapy, proper body mechanics, and core strengthening exercises for comprehensive management.
• Patients should be monitored for medication side effects and efficacy, with treatment plans adjusted accordingly.

Recent Guidelines

• The 2017 clinical practice guideline from the American College of Physicians recommends nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation for patients with chronic low back pain 1.
• Pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy, should be considered in patients who have had an inadequate response to nonpharmacologic therapy 1.

From the FDA Drug Label

In three of these studies there was a significantly greater improvement with cyclobenzaprine than with diazepam, while in the other studies the improvement following both treatments was comparable The efficacy of cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients. Analysis of the data from controlled studies shows that cyclobenzaprine produces clinical improvement whether or not sedation occurs.

Pharmaceutical therapy options for chronic lumbar strain include:

• Cyclobenzaprine hydrochloride tablets 5 mg, which has been shown to be effective in clinical trials 2
• Combination therapy with cyclobenzaprine hydrochloride tablets and other analgesics, such as naproxen, although this may increase the risk of side effects, primarily drowsiness 2

From the Research

Pharmaceutical Therapy Options for Chronic Lumbar Strain

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial medication of choice for chronic lumbar strain, as they have been shown to improve pain and disability levels in patients with low back pain 3, 4, 5.
• Duloxetine may also be beneficial in the treatment of chronic lumbar strain, as it has been found to improve pain and disability levels in patients with low back pain 3, 4.
• Other pharmacological compounds that may be effective in the treatment of chronic lumbar strain include baclofen, and opioids, although the evidence for these is not as strong as for NSAIDs and duloxetine 4, 5.
• Paracetamol, muscle relaxants, benzodiazepines, and antidepressants may not be effective in the treatment of chronic lumbar strain, as the evidence for these is limited or inconclusive 3, 4, 5.
• The use of opioids should be approached with caution, as they may increase the risk of adverse events such as nausea, headaches, constipation, and dizziness 5.

Safety and Efficacy of Pharmaceutical Therapy Options

• NSAIDs have been found to have a small effect on pain intensity and disability in patients with chronic low back pain, with low-certainty evidence for no evidence of an increased risk of adverse events 5.
• Opioids have been found to have a small effect on pain intensity and disability in patients with chronic low back pain, but may increase the risk of adverse events such as nausea, headaches, constipation, and dizziness 5.
• Duloxetine has been found to improve pain and disability levels in patients with low back pain, but the evidence for its safety and efficacy is not as strong as for NSAIDs 3, 4.

Clinical Approach to Chronic Lumbar Pain

• A systematic review of clinical practice guidelines recommends exercise and back school treatment as the best therapies for chronic low back pain, with pharmacotherapy indicated during short periods of time 6.
• The guidelines analyzed show similar therapeutic approaches, and the recommendations have been synthesized to allow clinical selection of the best treatment and avoid bad practices with their corresponding costs, providing a more efficient management of the patient 6.