Clinician Article

Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline.

  • Chou R
  • Deyo R
  • Friedly J
  • Skelly A
  • Weimer M
  • Fu R, et al.
Ann Intern Med. 2017 Apr 4;166(7):480-492. doi: 10.7326/M16-2458. Epub 2017 Feb 14. (Review)
PMID: 28192790
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  • Physical Medicine and Rehabilitation
    Relevance - 7/7
    Newsworthiness - 6/7
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 7/7
    Newsworthiness - 5/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 7/7
    Newsworthiness - 5/7
  • Special Interest - Pain -- Physician
    Relevance - 6/7
    Newsworthiness - 5/7


BACKGROUND: A 2007 American College of Physicians guideline addressed pharmacologic options for low back pain. New evidence and medications have now become available.

PURPOSE: To review the current evidence on systemic pharmacologic therapies for acute or chronic nonradicular or radicular low back pain.

DATA SOURCES: Ovid MEDLINE (January 2008 through November 2016), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and reference lists.

STUDY SELECTION: Randomized trials that reported pain, function, or harms of systemic medications versus placebo or another intervention.

DATA EXTRACTION: One investigator abstracted data, and a second verified accuracy; 2 investigators independently assessed study quality.

DATA SYNTHESIS: The number of trials ranged from 9 (benzodiazepines) to 70 (nonsteroidal anti-inflammatory drugs). New evidence found that acetaminophen was ineffective for acute low back pain, nonsteroidal anti-inflammatory drugs had smaller benefits for chronic low back pain than previously observed, duloxetine was effective for chronic low back pain, and benzodiazepines were ineffective for radiculopathy. For opioids, evidence remains limited to short-term trials showing modest effects for chronic low back pain; trials were not designed to assess serious harms. Skeletal muscle relaxants are effective for short-term pain relief in acute low back pain but caused sedation. Systemic corticosteroids do not seem to be effective. For effective interventions, pain relief was small to moderate and generally short-term; improvements in function were generally smaller. Evidence is insufficient to determine the effects of antiseizure medications.

LIMITATIONS: Qualitatively synthesized new trials with prior meta-analyses. Only English-language studies were included, many of which had methodological shortcomings. Medications injected for local effects were not addressed.

CONCLUSION: Several systemic medications for low back pain are associated with small to moderate, primarily short-term effects on pain. New evidence suggests that acetaminophen is ineffective for acute low back pain, and duloxetine is associated with modest effects for chronic low back pain.

PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42014014735).

Clinical Comments

Family Medicine (FM)/General Practice (GP)

A useful review of treatment options for a very common problem in primary care.

Family Medicine (FM)/General Practice (GP)

As a family physician, low back pain is a common problem amongst my patients, so knowing what treatments help the patient to recover sooner and experience less suffering until recovery is important. The finding that none of the medicines reviewed helps very much is important news.

General Internal Medicine-Primary Care(US)

Very helpful recent update of data on pharmacologic treatment of low back pain. Much of the information has not changed, but some has such as acetaminophen being ineffective.

General Internal Medicine-Primary Care(US)

As a general internist, back pain is often the chief complaint at an office visit. This study provides the evidence of effectiveness in using NSAIDs and muscle relaxants in treating the patients with acute back pain, and some benefits in using duloxetine in treating chronic back pain.

Physical Medicine and Rehabilitation

Updated review of the evidence for pharmacotherapy for acute and chronic low back pain provides changes in recommendations on certain medications that may be news to some providers. This article is important for providers in both primary care and specialty spine care.

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