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CMAJ. 2018 Jul 3;190(26):E786-E793. doi: 10.1503/cmaj.171333.

Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis.

Author information

1
The University of Sydney (Enke, H.A. New, C.H. New), Sydney Medical School Nepean, Kingswood, Australia; Westmead Hospital (H.A. New), Westmead, Australia; The University of Sydney (Mathieson, Latimer, Maher, Lin), Sydney School of Public Health; The University of Sydney and Concord Hospital (McLachlan), Faculty of Pharmacy and Centre for Education and Research on Ageing, Sydney, Australia dr.oliver.enke@gmail.com.
2
The University of Sydney (Enke, H.A. New, C.H. New), Sydney Medical School Nepean, Kingswood, Australia; Westmead Hospital (H.A. New), Westmead, Australia; The University of Sydney (Mathieson, Latimer, Maher, Lin), Sydney School of Public Health; The University of Sydney and Concord Hospital (McLachlan), Faculty of Pharmacy and Centre for Education and Research on Ageing, Sydney, Australia.

Abstract

BACKGROUND:

The use of anticonvulsants (e.g., gabapentin, pregabalin) to treat low back pain has increased substantially in recent years despite limited supporting evidence. We aimed to determine the efficacy and tolerability of anticonvulsants in the treatment of low back pain and lumbar radicular pain compared with placebo.

METHODS:

A search was conducted in 5 databases for studies comparing an anticonvulsant to placebo in patients with nonspecific low back pain, sciatica or neurogenic claudication of any duration. The outcomes were self-reported pain, disability and adverse events. Risk of bias was assessed using the Physiotherapy Evidence Database (PEDro) scale, and quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Data were pooled and treatment effects were quantified using mean differences for continuous and risk ratios for dichotomous outcomes.

RESULTS:

Nine trials compared topiramate, gabapentin or pregabalin to placebo in 859 unique participants. Fourteen of 15 comparisons found anticonvulsants were not effective to reduce pain or disability in low back pain or lumbar radicular pain; for example, there was high-quality evidence of no effect of gabapentinoids versus placebo on chronic low back pain in the short term (pooled mean difference [MD] -0.0, 95% confidence interval [CI] -0.8 to 0.7) or for lumbar radicular pain in the immediate term (pooled MD -0.1, 95% CI -0.7 to 0.5). The lack of efficacy is accompanied by increased risk of adverse events from use of gabapentinoids, for which the level of evidence is high.

INTERPRETATION:

There is moderate- to high-quality evidence that anticonvulsants are ineffective for treatment of low back pain or lumbar radicular pain. There is high-quality evidence that gabapentinoids have a higher risk for adverse events.

PROTOCOL REGISTRATION:

PROSPERO-CRD42016046363.

Conflict of interest statement

Competing interests: Stephanie Mathieson, Andrew McLachlan, Jane Latimer, Christopher Maher and C.-W. Christine Lin were investigators on the included PRECISE study, which was an investigator-initiated trial evaluating pregabalin for sciatica, funded by the National Health and Medical Research Council of Australia with in-kind research support from Pfizer (ACTRN12613000530729). These authors did not contribute to any data management regarding this study for this review. Christopher Maher reports receiving a grant from Pfizer, outside the submitted work; Andrew McLachlan reports receiving a grant from GlaxoSmithKline Australia. No other competing interests were declared.

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