From the Guidelines
Gabapentin and pregabalin (Lyrica) should not be prescribed as first-line treatment for back pain, but may be considered for cases with clear neuropathic components, such as radiculopathy, at the lowest effective dose for the shortest necessary duration. According to the American College of Physicians guidelines, non-pharmacological approaches should be used as first-line treatment for back pain, followed by NSAIDs or muscle relaxants if needed 1. The FDA has not issued specific guidelines stating that gabapentin and pregabalin should not be prescribed for back pain, but these medications are FDA-approved for neuropathic pain conditions, not specifically for general back pain. Recent evidence suggests limited effectiveness for non-specific low back pain, and these medications carry risks including sedation, dizziness, and potential for dependence 1.
Some key points to consider when prescribing gabapentin and pregabalin for back pain include:
- Reserving these medications for cases with clear neuropathic components, such as radiculopathy
- Prescribing at the lowest effective dose for the shortest necessary duration
- Monitoring patients for side effects and effectiveness, with regular reassessment of the need for continued therapy
- Considering alternative treatments, such as NSAIDs or muscle relaxants, for non-specific low back pain
- Being aware of the potential risks and benefits of these medications, including the risk of dependence and adverse events such as dizziness and sedation 1.
It's also important to note that patients with chronic pain may experience concurrent depression, and depression can exacerbate physical symptoms including pain, so patients with co-occurring pain and depression may benefit from antidepressant medication 1. However, tricyclic antidepressants are potentially inappropriate for older adults due to their anticholinergic effects 1.
From the Research
FDA Guidelines for Gabapentin and Lyrica
- The FDA has approved gabapentin for the treatment of postherpetic neuralgia, while pregabalin (Lyrica) has been approved for postherpetic neuralgia, neuropathic pain associated with diabetic neuropathy or spinal cord injury, and fibromyalgia 2.
- Despite these limited indications, gabapentin and pregabalin are widely prescribed off-label for various other pain syndromes, including back pain 2.
Efficacy of Gabapentin and Lyrica for Back Pain
- There is limited evidence to support the use of gabapentinoids for back pain, and clinicians should be aware of the limited evidence and uncertain potential benefits for most off-label uses 2.
- A review of published comparative effectiveness trials and data submitted to the FDA for approval found that gabapentinoids have modest pain benefits, and the placebo response in these trials was frequently one-third to one-half as great as the pain benefit demonstrated by the gabapentinoid 3.
Alternative Treatments for Back Pain
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to treat back pain, and there is moderate quality evidence that NSAIDs are slightly more effective than placebo for short-term pain reduction and disability 4, 5.
- COX-2 inhibitors, a type of NSAID, have been shown to be equally effective as traditional NSAIDs for acute low back pain, but with fewer side effects 5.
Prescribing Gabapentin and Lyrica for Back Pain
- Clinicians who prescribe gabapentinoids off-label for back pain should be cautious and aware of the limited evidence, and should acknowledge to patients that potential benefits are uncertain for most off-label uses 2.
- The FDA has strengthened the warnings for both gabapentin and pregabalin to emphasize the central nervous system side effects and the risk of respiratory depression, especially when combined with other centrally acting drugs 3.