What treatment approach is recommended for a 59-year-old male patient with back pain and diarrhea, who has shown improvement with Lomotil (diphenoxylate)?

From the Guidelines

I strongly recommend providing the patient with a bed wedge to help alleviate his back pain, as it serves as a non-pharmacological intervention to maintain progress and properly support his spine during sleep. Since the patient reports improvement in his condition, the bed wedge can help decompress the back by creating an inclined surface that reduces pressure on the spine and promotes better alignment 1. The patient's back pain, which began on April 26,2025, may benefit from this intervention, especially considering the limited evidence for medication use in low back pain treatment, as noted in the guideline from the American College of Physicians and the American Pain Society 1.

Some key points to consider for the patient's treatment include:

• The use of systemic corticosteroids is not recommended for low back pain due to lack of evidence showing benefits over placebo 1.
• Nonpharmacologic therapies, such as spinal manipulation, intensive interdisciplinary rehabilitation, and exercise therapy, have proven benefits for acute and chronic low back pain 1.
• The patient's previous response to Lomotil for diarrhea suggests that this medication can be effective for him, but it should be used judiciously and with consideration of dietary modifications to manage symptoms 1.
• The bed wedge should be used consistently each night, positioned at the head of the bed with the inclined portion supporting the upper body, to achieve optimal decompression of the lumbar spine and potentially prevent future episodes of back pain.

Regarding his diarrhea, the previously prescribed Lomotil (diphenoxylate/atropine) for 3 days was effective, and no further intervention is needed at this time as the symptom has resolved. However, if diarrhea recurs, the patient should be advised to maintain adequate hydration and consider dietary modifications (avoiding spicy foods, dairy, and high-fat meals) before reinitiating medication.

From the FDA Drug Label

INDICATIONS AND USAGE Diphenoxylate hydrochloride and atropine sulfate tablets are effective as adjunctive therapy in the management of diarrhea. The patient's complaint of diarrhea was previously treated with Lomotil, which is a brand name for Diphenoxylate, and it worked for him.

• Diarrhea treatment: The patient's previous treatment with Lomotil (Diphenoxylate) was effective, but there is no information in the provided drug labels that directly supports the use of a bed wedge for back pain or its relation to diarrhea treatment 2.
• Back pain: There is no information provided about the patient's back pain or the use of a bed wedge in the drug labels 2, 2, 2. The FDA drug label does not answer the question.

From the Research

Patient Complaints and Treatment

• The patient is complaining of back pain and diarrhea, and has been prescribed Lomotil for 3 days two weeks ago, which worked for him.
• The patient is requesting a bed wedge to help decompress his back while sleeping.

Low Back Pain Treatment Guidelines

• According to 3, low back pain guidelines regularly recommend the use of physical exercise for non-specific low back pain, and early non-pharmacological treatment is endorsed.
• The aim of physical treatments is to improve function and prevent disability from getting worse, and there is no evidence available to show that one type of exercise is superior to another.
• The Danish, United States of America, and the United Kingdom Guidelines recommend the use of exercise on its own, or in combination with other non-pharmacological therapies, such as tai chi, yoga, massage, and spinal manipulation.

Diagnosis and Treatment of Low Back Pain

• As stated in 4, low back pain encompasses three distinct sources: axial lumbosacral, radicular, and referred pain, and the prevalence of low back pain in the general US adult population is 10-30% annually.
• A multidisciplinary, logical approach to treatment is most effective and can include multimodal medical, psychological, physical, and interventional approaches, as mentioned in 4 and 5.
• The North American Spine Society's Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain, as outlined in 5.

Management of Back Pain

• According to 6, a biopsychosocial approach to back pain provides the best clinical framework, and a detailed history and physical examination with a thorough workup are required to exclude emergent or nonoperative etiologies of back pain.
• The treatment of back pain first uses conventional therapies including lifestyle modifications, nonsteroidal anti-inflammatory drugs, physical therapy, and cognitive behavioral therapy, as stated in 6.
• Implementation of clinical practice guidelines for neck and low back pain in outpatient physical therapy was associated with changes in clinician and patient outcomes, but not in patient pain and disability scores, as found in 7.