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Evidence review for pharmacological management of sciatica

Low back pain and sciatica in over 16s: assessment and management

Evidence review A

NICE Guideline, No. 59

.

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-2188-1

1. Pharmacological management of sciatica

1.1. Review question

What is the clinical and cost effectiveness of pharmacological treatment in the management of sciatica?

1.1. Introduction

Sciatica is a general term for pain in the leg as a result of nerve compression or irritation in the lumbar spine. This is sometimes referred to as radicular pain. Many people with low back pain have referred pain in the leg, without nerve compression. The commonest cause is impingement or inflammation of the lumbosacral nerve roots and is frequently associated with herniation of a lumbar intervertebral disc. In older people, additional anatomical changes may be important. Anatomical structures and abnormal movement in the back can also cause pain to be felt or ‘referred’ to the leg. It can be difficult to differentiate referred pain from sciatica, and the two may co-exist. The pharmacological management of back pain, including referred pain, was included in ‘Low back pain and sciatica in over 16s: assessment and management’ (NG59).

People with sciatica typically have severe pain at onset and a slower and less complete recovery than people with back pain without sciatica. A review of pharmacological interventions for sciatica is important because people with sciatica commonly present in primary care. Drugs for neuropathic pain are frequently prescribed for sciatica in addition to opioids and other analgesics. There is high variability of prescribing volumes between CCGs and different population groups. A significant proportion of people continue taking medication for sciatica in the longer term.

When NG59 was first published in 2016, the guideline cross-referenced ‘Neuropathic pain in adults: pharmacological management in non-specialist settings’ (CG173) for the pharmacological management of sciatica. A MHRA drug safety update in April 2019 advised that gabapentin and pregabalin were reclassified as controlled drugs. This triggered an exceptional surveillance review for NG59. The frequent presentation for relief of leg pain associated with back pain and sciatica in primary care, the unknown efficacy of drugs for neuropathic pain in sciatica, and the reclassification of some drugs used to treat sciatica coupled with the variation in prescribing patterns warrants a fresh review of the pharmacological management of sciatica.

1.1.2. Summary of the protocol

Table 1. PICO characteristics of review question.

Table 1

PICO characteristics of review question.

This review focuses on the management of sciatica only. Pharmacological management of low back pain, and mixed populations of low back pain and sciatica are considered in a separate chapter in the full guideline: Low back pain and sciatica in over 16s: assessment and management. For full details see the review protocol in Appendix A.

1.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

Eight randomised-controlled trial studies were included in the review17, 26, 33, 47, 57, 71, 85, 144; these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3, Table 4, Table 5, Table 6, Table 7).

Clinical studies comparing the following interventions was identified:

  • Non-steroidal anti-inflammatory drugs compared to placebo
  • Benzodiazepines compared to placebo
  • Gabapentinoids compared to placebo
  • Corticosteroids compared to gabapentinoids
  • Corticosteroids compared to placebo.

No relevant clinical studies comparing any other interventions were identified. No Cochrane reviews were included. Due to insufficient evidence, comparative non-randomised studies were checked for eligibility, of which none satisfied the inclusion criteria.

See also the study selection flow chart in Appendix C, study evidence tables in Appendix D, forest plots in Appendix E and GRADE tables in Appendix F.

1.1.4.2. Excluded studies

Three Cochrane reviews were identified but were not included in the review as they included the wrong populations for this review protocol (either mixed neuropathic pain32 or studies where the focus was low back pain rather than sciatica112, 113).

See the excluded studies list in Appendix J.

1.1.5. Summary of studies included in the effectiveness evidence

Table 2. Summary of studies included in the evidence review.

Table 2

Summary of studies included in the evidence review.

See Appendix D for full evidence tables.

1.1.6. Summary of the effectiveness evidence

Table 3. Clinical evidence summary: non-steroidal anti-inflammatory drugs compared to placebo.

Table 3

Clinical evidence summary: non-steroidal anti-inflammatory drugs compared to placebo.

Table 4. Clinical evidence summary: benzodiazepines compared to placebo.

Table 4

Clinical evidence summary: benzodiazepines compared to placebo.

Table 5. Clinical evidence summary: gabapentinoids compared to placebo.

Table 5

Clinical evidence summary: gabapentinoids compared to placebo.

Table 6. Clinical evidence summary: Corticosteroids compared to placebo.

Table 6

Clinical evidence summary: Corticosteroids compared to placebo.

Table 7. Clinical evidence summary: Corticosteroids compared to gabapentinoids.

Table 7

Clinical evidence summary: Corticosteroids compared to gabapentinoids.

See Appendix F for full GRADE tables.

1.1.7. Economic evidence

1.1.7.1. Included studies

No health economic studies were included.

1.1.7.2. Excluded studies

One economic study relating to this review question was identified but was excluded due to a combination of limited applicability and methodological limitations.38, 75 This is listed in Appendix J, with reasons for exclusion given.

See also the health economic study selection flow chart in Appendix G.

1.1.8. Summary of included economic evidence

No study was included.

1.1.9. Economic model

This area was not prioritised for new cost-effectiveness analysis.

1.1.10. Evidence statements

Effectiveness

See the summary of evidence in Table 3, Table 4, Table 5, Table 6, Table 7.

Economic

  • No relevant economic evaluations were identified.

1.1.11. The committee’s discussion and interpretation of the evidence

1.1.11.1. The outcomes that matter most

The outcomes for this review were: quality of life, pain severity, function, psychological distress, healthcare utilisation, adverse events (morbidity and mortality), and responder criteria for pain and function. The committee agreed that quality of life, pain severity, function and psychological distress were critical to decision making. Each of these outcomes are important to people with sciatica and are important tools for monitoring the condition. The remaining outcomes were considered as important for decision making.

There was limited evidence for all outcomes relevant to this review protocol. No studies reported healthcare utilisation as an outcome. As healthcare use was not a critical outcome, the committee agreed they could formulate recommendations without this information.

1.1.11.2. The quality of the evidence

The quality of the evidence according to GRADE criteria varied from high to very low, with the majority being of moderate quality. Where evidence was downgraded this was mostly due to imprecision in the point estimate. For gabapentinoids compared to placebo and steroids compared to gabapentinoids, some outcomes were also downgraded due to risk of bias due to baseline differences, incomplete outcome reporting and trial design (discussed below).

The quality was considered by the committee when making recommendations. The recommendation against the use of gabapentinoids was made with careful consideration by the committee as there were 2 outcomes for pain severity at less than 4 months that showed conflicting clinical efficacy. High quality evidence showed no clinically important difference, and evidence of moderate quality showed a clinically important benefit. The difference in evidence quality and other limitations (discussed in 1.1.12.3 benefits and harms section) resulted in the committee placing more weight on the higher quality evidence when making the recommendation.

It was noted that one of the studies informing the evidence for gabapentinoids was an enriched enrolment trial. The committee discussed the drawbacks of this study for informing true response in an untested population. However it was agreed this was accounted for in the risk of bias rating and consequently the quality of evidence. Due to the limited amount of evidence it was agreed more informative to retain this study within the review, noting its limitations.

There was an absence of evidence for paracetamol, opioids, antidepressants, nefopam, antiepileptic drugs other than gabapentinoids and muscle relaxants other than benzodiazepines. All other interventions were at least compared to placebo, with the only head-to-head comparison being corticosteroids compared to gabapentinoids. In some cases, the committee agreed it was appropriate to make recommendations based on expert consensus opinion. Consensus recommendations were made where there was existing knowledge of harms considered alongside the absence of evidence of benefit. For others, the committee recommended further research. These were considered appropriate where there was some uncertainty as to whether the medicines may be of benefit, and the known risk of harms was considered to be lower. There were some medicines for which the committee agreed not to make any recommendation, nor recommend further research. These included medicines rarely prescribed for sciatica in current clinical practice and so the committee agreed the absence of a recommendation would not change clinical practice and a research recommendation would not be of value. Further detail of how these considerations were made for each intervention is covered in the section below on benefits and harms.

Non-randomised studies were included in the search for this review. However, none were identified that fulfilled the criteria for inclusion.

1.1.11.3. Benefits and harms

Non-steroidal anti-inflammatory drugs (NSAIDs) compared to placebo

Two studies reported outcomes comparing NSAIDs to placebo. The evidence was for pain severity and adverse events (morbidity) at up to 4 months. The evidence relating to these outcomes was rated as high to moderate quality and showed no clinically important difference between the two interventions. While the evidence was only in two different types of NSAIDs (meloxicam and diclofenac), the committee agreed that the evidence may be applicable to other types of NSAID. The committee agreed that there was insufficient evidence of benefit to support a recommendation for the use of NSAIDs in people with sciatica. The committee discussed that most clinicians were aware of the BNF drug monographs highlighting the risks of harms from NSAIDs. The committee also noted that NSAIDs were unlikely to be continued if they were not helpful. Therefore, they agreed that a recommendation should not be made for or against their use without sufficient evidence demonstrating benefit or harm from NSAIDs, but that it was important to highlight the risks and lack of evidence for benefit in a recommendation as well as including a research recommendation on the topic.

Benzodiazepines compared to placebo

One study reported an outcome comparing benzodiazepines to placebo. The evidence was for responder criteria for pain at up to 4 months. This suggested that more people receiving placebo had a 50% reduction in pain compared to those receiving benzodiazepines. The difference between placebo and benzodiazepines was considered clinically important although there was some uncertainty in the estimate. The evidence relating to this outcome was of moderate quality as a result of the imprecision. There was no evidence from any of the critical outcomes specified in the protocol. Given the lack of evidence for benefit and the evidence of worse outcome for pain, alongside the potential harms of misuse of benzodiazepines, the committee agreed to recommend against their use for sciatica.

Antiepileptics (gabapentinoids) compared to placebo

Three studies reported outcomes comparing gabapentinoids to placebo. These outcomes included quality of life, pain severity, physical function, psychological distress and adverse events (morbidity) at short and longer term follow up. Adverse events (mortality) was also reported, but at up to 4 months only. These outcomes varied from high to very low quality.

There were 2 separate outcomes for pain at less than 4 months. One showed no clinically important difference (based on 2 studies and 408 people rated as high quality evidence), whereas the other showed a clinically important benefit (this evidence was from 1 study and 43 people rated as moderate quality evidence). Given the difference in quality of evidence and the small number of participants informing the latter outcome, the committee agreed that they would attach more weight to the better quality evidence showing no clinically important difference while making recommendations. Furthermore, there was no clinically important difference in quality of life, function and psychological distress, with a clinically important harm from gabapentinoids for adverse events (morbidity) at longer term follow up. Although there was some imprecision associated with all of these outcomes, the effects consistently suggested no difference between interventions (with the exception of adverse events as noted above).

The committee questioned the dose of pregabalin used in one study (Ko 201671) where the dose appeared to be particularly low (7.5mg twice daily). Stakeholder feedback revealed that this was a typographical error in the study and that the dose was actually 75mg twice daily, which better reflects the dose used in current practice.

The committee discussed their understanding of the potential harms of misuse of gabapentinoids, as well as their reclassification as controlled drugs in 2019. They therefore agreed to recommend against their use for sciatica.

The committee agreed that whilst all the evidence was for gabapentinoids, there was no reason to suggest other antiepileptics would be more effective for people with sciatica, nor have fewer associated harms, and therefore agreed the recommendation should cover all antiepileptics.

Corticosteroids compared to placebo

One study compared corticosteroids to placebo. The evidence included quality of life, pain severity, function and responder criteria at up to 4 months and longer term. Adverse events (morbidity) was also reported, but at less than 4 months only. These outcomes varied from high to moderate quality.

There was evidence of a clinically important benefit for one of the two outcomes for quality of life at up to 4 months (the physical component summary of SF-36) and for both quality of life measures at the longer term follow up. There was some imprecision associated with all of the quality of life results. No clinically important difference was observed for pain severity or function, with imprecision only associated with the longer term follow up results. Given the lack of effect on pain severity and function, the committee agreed that the suggested benefits for quality of life from a single study were not convincing enough to convey a benefit of corticosteroids. There was also evidence of a clinically important harm in adverse events (morbidity) at up to 4 months.

Corticosteroids compared to antiepileptics (gabapentinoids)

One study reported outcomes comparing corticosteroids to gabapentinoids. These outcomes included quality of life, pain severity and function at up to 4 months. The evidence relating to these outcomes ranged from low to very low quality. The sample size was small (n=40) leading to very wide confidence intervals and downgrading for imprecision in all of the results with the exception of function. There was evidence of a worse outcome with corticosteroids for one of the 2 quality of life outcomes (the physical component score of SF-36) while the other showed no clinically important difference. However, the difference between the 2 groups of participants was minimal after taking into account baseline differences in the 2 randomised groups. There was evidence of clinically important benefit for corticosteroids in terms of pain severity, but no clinically important difference for function at up to 4 months. The committee also noted that the dose of oral corticosteroids was low and the dose of gabapentinoids used in this study were particularly low (pregabalin 7.5mg twice daily or gabapentin 100mg three times daily), and so this may have had an effect on the outcomes. Given the size of the study (40 people), low quality of the evidence, and concerns about the doses used, the committee agreed that little weight could be placed on this evidence.

The committee agreed that with lack of evidence of benefit compared to placebo, associated evidence of harms, and unconvincing results when compared to gabapentinoids, a recommendation should be made against the use of corticosteroids for sciatica. The committee noted that the evidence was only for oral corticosteroids (rather than other routes of administration) and therefore the recommendation is specific to oral use.

Other drug classes

The committee was surprised at the lack of evidence comparing opioids to placebo or other medicines. They agreed that opioids pose a significant risk of harm to people when used incorrectly. Through clinical experience, they agreed that long-term use of opioids was unlikely to be beneficial and given that the harms from opioids are more likely for people when they have been on them for a longer period of time, they agreed to recommend against their use for chronic sciatica. Due to the lack of evidence about their effectiveness in acute sciatica, and committee consensus that opioids may be of benefit when used short term for pain relief, the committee agreed that further research was warranted to inform updates of this guideline. A research recommendation was therefore drafted for this population.

There was no evidence comparing antidepressants to placebo or other medicines. The committee’s clinical experience was that antidepressants are commonly used for sciatica and it was noted that they are recommended for other causes of neuropathic pain. The committee agreed there was a lower risk of harm compared to some of the other medicines (for example, long term use of opioids), however their widespread use despite the lack of evidence for their use for sciatica led the committee to recommend further research to inform future updates of this guidance.

There was no evidence for the use of paracetamol, nefopam or muscle relaxants other than benzodiazepines in sciatica. The committee did not make a recommendation regarding these. The committee noted that these are not widely prescribed for management of sciatica alone in current practice and therefore neither a recommendation nor further research were required. A recommendation for the use of paracetamol for people with low back pain is already included within this guideline.

Given the lack of clinical benefit for any of the pharmacological treatments for sciatica included in this review, the committee made no recommendations to offer a specific pharmacological agent. They recommended against use of other treatments where the known potential risks are very likely to outweigh any as yet unknown clinical benefit (gabapentinoids and other antiepileptics, opioids, benzodiazepines). They considered that the recommendations included in the guideline for non-pharmacological or invasive treatment options should be considered as the basis for managing sciatica, as appropriate.

1.1.11.4. Cost effectiveness and resource use

No health economic evidence was found for this question.

The committee agreed that there was no consistent evidence of effectiveness for the management of sciatica for any of the drugs included in the review protocol.

As antiepileptics, oral corticosteroids and benzodiazepines were also found to be harmful, they are unlikely to be cost effective in treating sciatica. Therefore, the recommendation not to use these drugs should reduce drug-related harms. It might lead to an increased use of other recommended treatments but overall should improve the efficiency of the NHS.

The cost effectiveness of antidepressants and opioid analgesics in the treatment of sciatica is uncertain and therefore research has been prioritised.

1.1.11.5. Other factors the committee took into account

The potential harms associated with abrupt discontinuation of certain medicines when used long term prompted the committee to include recommendations on discussing the harms of continuing these medicines with people who are already receiving them. They agreed to include a consensus recommendation that healthcare professionals consider how to withdraw them appropriately if agreed that they should no longer be used. The committee was aware that NICE has a guideline in development for safe prescribing and withdrawal management of medicines associated with dependence or withdrawal symptoms. The committee were also aware of a review from Public Health England (Dependence and withdrawal associated with some prescribed medicines, 201982, 134) that described the association of abrupt cessation of such drugs with the emergence of withdrawal symptoms. These symptoms might be reduced by using a tapering regime. This helped inform the recommendations in this review. They also discussed the importance of discussion with individual patients about the options for sciatica management, taking into account clinical features, comorbidities and the patient’s preferences and expectations. It was agreed that the decision to stop medication should follow an informed discussion with the patient and be a shared decision. The committee noted that this echoed one of the themes in the NICE guideline on Patient experience in adult NHS services and wished to draw attention to section 1.3 “Tailoring healthcare services for each patient” which covers an individualised approach, taking account of patient view and preferences, and section 1.5 including “shared decision-making”.

The committee noted the importance of diagnosing sciatica correctly. Sciatica may be misdiagnosed in people with chronic muscular low back pain referring to the leg or leg pain for another reason. Response to medicines is likely to vary depending on the cause of leg pain. The committee considered this while looking at the evidence, as some studies confirmed the clinical presentation of sciatica symptoms with the use of imaging while others did not.

The committee discussed the fact that the symptoms of sciatica can be affected by a range of biological, social and psychological factors. The committee thought that this might explain the heterogeneity in response to treatment for sciatica. They wished to draw attention to the non-pharmacological treatments recommended in this guideline which should be considered alongside pharmacological interventions.

For the recommendations on opioids where separate decisions have been made for acute and chronic sciatica it was considered important to note that chronic pain is pain which lasts for more than three months. Pain may be continuous or intermittent and may fluctuate in intensity. When pain becomes chronic a number of unhelpful neuroadaptations occur which make pain refractory to usual interventions. All pain is influenced by psychological and social factors but these become much more prominent when pain becomes chronic. This means that treatments designed to interrupt pain signals which are successfully used to treat acute pain have little benefit when treating chronic pain. Also, for this reason, exacerbations of chronic pain are less likely to respond to treatment.

1.1.12. Recommendations supported by this evidence review

This evidence review supports recommendations 1.2.16 to 1.2.21 and the research recommendations on opioids for the management of acute sciatica and antidepressants and NSAIDs for the management of sciatica.

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Appendices

Appendix B. Literature search strategies

Pharmacological management of sciatica search strategy A

This literature search strategy was used for the following review question:

  • What is the clinical and cost effectiveness of pharmacological treatment in the management of sciatica?

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.93

For more information, please see the Methodology review published as part of the accompanying documents for this guideline.

B.1. Clinical search literature search strategy

Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies for interventions as these concepts may not be well described in title, abstract or indexes and therefore difficult to retrieve. Search filters were applied to the search where appropriate.

Table 9. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

Cochrane Library (Wiley) search terms

Epistemonikos search terms

B.2. Health Economics literature search strategy

Health economic evidence was identified by conducting a broad search relating to low back pain and sciatica population in NHS Economic Evaluation Database (NHS EED – this ceased to be updated after March 2015) and the Health Technology Assessment database (HTA) with no date restrictions. NHS EED and HTA databases are hosted by the Centre for Research and Dissemination (CRD). Additional searches were run on Medline and Embase.

Table 10. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

NHS EED and HTA (CRD) search terms

Appendix D. Effectiveness evidence

Download PDF (379K)

Appendix E. Forest plots

Appendix G. Economic evidence study selection

Image niceng59er1appgf1

* Non-relevant population, intervention, comparison, design or setting; non-English language

Appendix H. Economic evidence tables

No studies were included.

Appendix I. Health economic model

No original economic modelling was undertaken.

Appendix K. Research recommendations – full details

K.1.1. Research recommendation

What is the clinical and cost effectiveness of opioids for the management of acute sciatica?

K.1.2. Why this is important

Opioids are commonly used for management of pain, however in recent years concern has arisen about the risks of dependence associated with opioids and other related harms. There was a lack of evidence for the use of opioids for sciatica identified in the review. Whilst their use for chronic sciatica is not recommended, there may be some benefit from using them short term for acute sciatica. Research is required to determine whether this is true.

K.1.3. Rationale for research recommendation

Importance to ‘patients’ or the populationThere are a limited number of effective treatments for sciatica and no oral pharmacological treatments are currently recommended for use. Effective treatment of acute sciatica could prevent this from becoming chronic in those where it would not have resolved spontaneously and would be of benefit to patients.
Relevance to NICE guidanceNo evidence was identified for the use of opioids in the management of sciatica. Concerns about the harms of using opioids long term informed a recommendation against their use for chronic sciatica, but no recommendation was made for acute sciatica. Research on this topic would enable a recommendation to be made in future updates of this guideline.
Relevance to the NHSThe outcome of this research may offer a pharmacological treatment option for people with acute sciatica and may also prevent people from progressing to chronic sciatica.
National prioritiesMedium
Current evidence baseNo evidence for opioids was identified in the review of pharmacological treatment for sciatica described in this evidence review. Although there are known harms of long term use of opioids, evidence for short term use for acute sciatica is required.
Equality considerationsNone known

K.1.4. Modified PICO table

PopulationPeople aged 16 and over with acute sciatica.
InterventionOpioids
ComparatorPlacebo
Outcome

Critical:

Quality of life (for example EQ5D or SF36); pain severity (for example VAS or NRS), function (RMDQ or ODI), Psychological distress (HADS, GHQ, BDI or STAI)

Important:

Healthcare utilisation, Adverse events (morbidity and mortality), Responder criteria (≥ 30% improvement in pain or function)

Study designRandomised controlled trial
TimeframeShort term follow up is required to determine the use for acute sciatica (less than 3 months duration) however long term follow up would also be of benefit to determine if benefits are maintained or if there are any longer term adverse effects after treatment stops.
Additional informationNone

K.1.5. Research recommendation

What is the clinical and cost effectiveness of antidepressants for the management of sciatica?

K.1.6. Why this is important

Antidepressants are very widely prescribed for sciatica and other neuropathic pain conditions. NICE’s guideline for pharmacological management of neuropathic pain (CG173) recommends amitriptyline and duloxetine as 2 of the possible initial treatment options for neuropathic pain, however it was noted that whilst sciatica was previously considered within that guideline, there was very little evidence in populations with sciatica. In this updated review, no evidence relevant to this review protocol was identified for antidepressants in people with sciatica. Given how commonly they are used, evidence is required to inform recommendations specific to people with sciatica.

K.1.7. Rationale for research recommendation

Importance to ‘patients’ or the populationThere are a limited number of effective treatments for sciatica and no oral pharmacological treatments are currently recommended for use. Antidepressants are commonly prescribed and therefore evidence of their effectiveness in this condition is important for people with sciatica to determine whether these should be recommended.
Relevance to NICE guidanceNo evidence was identified for the use of antidepressants in the management of sciatica. Research on this topic would enable a recommendation to be made in future updates of this guideline.
Relevance to the NHSThe outcome of this research may offer a pharmacological treatment option for people with sciatica.
National prioritiesMedium
Current evidence baseNo evidence for antidepressants relevant to the review protocol was identified in the review of pharmacological treatment for sciatica described in this evidence review.
Equality considerationsNone known

K.1.8. Modified PICO table

PopulationPeople aged 16 and over with sciatica.
Intervention

Antidepressants:

SSRIs

SNRIs

TCAs

Other antidepressants

ComparatorPlacebo
Outcome

Critical:

Quality of life (for example EQ5D or SF36); pain severity (for example VAS or NRS), function (RMDQ or ODI), Psychological distress (HADS, GHQ, BDI or STAI)

Important:

Healthcare utilisation, Adverse events (morbidity and mortality), Responder criteria (≥ 30% improvement in pain or function)

Study designRandomised controlled trial
TimeframeShort term and long term follow up (minimum 1 year) is required to determine the use for acute and chronic sciatica and also to determine whether benefits are maintained or if there are long term adverse effects.
Additional informationNone

K.1.9. Research recommendation

What is the clinical and cost effectiveness of NSAIDs for the management of sciatica?

K.1.10. Why this is important

NSAIDs are widely used for the management of pain, including sciatica. In this updated evidence review, there was very limited evidence for their use in people with sciatica. Given the side effect profile and their common use, evidence is required to inform recommendations specific to people with sciatica.

K.1.11. Rationale for research recommendation

Importance to ‘patients’ or the populationThere are a limited number of effective treatments for sciatica and no oral pharmacological treatments are currently recommended for use. NSAIDs are commonly used and therefore evidence of their effectiveness in this condition is important for people with sciatica to determine whether these should be recommended.
Relevance to NICE guidanceLimited evidence was identified for the use of NSAIDs in the management of sciatica. Research on this topic would enable a recommendation to be made in future updates of this guideline.
Relevance to the NHSThe outcome of this research may offer a pharmacological treatment option for people with sciatica.
National prioritiesLow
Current evidence baseVery limited evidence for NSAIDs relevant to the review protocol was identified in the review of pharmacological treatment for sciatica. The committee considered this insufficient to make a recommendation for or against their use.
Equality considerationsNone known

K.1.12. Modified PICO table

PopulationPeople aged 16 and over with sciatica.
InterventionNSAIDs
ComparatorPlacebo
Outcome

Critical:

Quality of life (for example EQ5D or SF36); pain severity (for example VAS or NRS), function (RMDQ or ODI), Psychological distress (HADS, GHQ, BDI or STAI)

Important:

Healthcare utilisation, Adverse events (morbidity and mortality), Responder criteria (≥ 30% improvement in pain or function)

Study designRandomised controlled trial
TimeframeShort term and long term follow up (minimum 1 year) is required to determine the use for acute and chronic sciatica and also to determine whether benefits are maintained or if there are long term adverse effects.
Additional informationNone

Final

Evidence review underpinning recommendations 1.2.16 to 1.2.21 and research recommendations in the NICE guideline

This evidence review was developed by the National Guideline Centre

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2020.
Bookshelf ID: NBK562934PMID: 33090751

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