Evidence statementsEvidence to recommendations

One systematic review was identified that included 65 trials in people with acute (< 12 weeks) or chronic (> 12 weeks) non-specific low back pain treated with traditional NSAIDs or COX–2 inhibitors. NSAID therapy was found to be associated with a reduction in pain intensity compared with placebo for chronic low back pain. Limited evidence was found that NSAIDs reduce pain intensity compared with paracetamol for chronic low back pain. No studies comparing NSAIDs to opioids on patients with chronic low back pain were found. NSAIDs are associated with more side effects than placebo or paracetamol. (1++) (Roelofs, P. D. D. M., Deyo, R. A., Koes, B. W. et al, 2008)

No cost effectiveness studies were identified for oral NSAIDs

Paracetamol should normally be the first treatment option.
Insufficient evidence found concerning long term use of oral NSAIDs/COX-2 therefore recommendation is that they are short term treatments when paracetamol alone is insufficient.
There is insufficient evidence to preferentially prescribe either weak opioids or preferentially prescribe NSAIDs for people who obtain insufficient benefit from paracetamol
At the time of guideline publication, the following NSAIDs, and COX-2 inhibitors, are licensed for use for people with back pain: acemetacin, dexibuprofen, diclofenac sodium, fenbufen, fenoprofen, flurbiprofen, ibuprofen, indometacin, ketoprofen, naproxen, piroxicam, sulindac, tenoxicam, tiaprofenic acid
Cost effectiveness considerations: paracetamol, NSAIDs and weak opioids are available as generics and treatment costs are expected to be similar. Effectiveness of paracetamol is good in most patients. In some patients, there are moderate to severe side effects associated with NSAIDs.
The Osteoarthritis guideline found PPI cost effective for both long and short term use. Modelling was carried out for over 45 age group. The cost effectiveness was driven by side effects and the risk from NSAIDs is likely to be similar for people with OA or low back pain similar ages.
The Osteoarthritis guideline observed a consistent difference between etoricoxib 60 mg and the other drugs in the economic model, and therefore in line with the original aim of the economic model, advice is given against the use of etoricoxib 60 mg.

From: 11, Pharmacological therapies

Cover of Low Back Pain
Low Back Pain: Early Management of Persistent Non-specific Low Back Pain [Internet].
NICE Clinical Guidelines, No. 88.
National Collaborating Centre for Primary Care (UK).
Copyright © 2009, Royal College of General Practitioners.

All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher.

PubMed Health. A service of the National Library of Medicine, National Institutes of Health.