Medicine
In urgent and primary care settings, when a patient requests medication for acute low back pain without radicular symptoms, I typically prescribe naproxen and cyclobenzaprine, adding oxycodone/acetaminophen if the pain seems especially severe. But two recent articles in American Family Physician will likely lead me to change my practice.
The first article is a Medicine by the Numbers that reviewed the number needed to treat (NNT) and number needed to harm (NNH) from a pooled analysis of trials evaluating cyclobenzaprine for low back pain. Compared to placebo, cyclobenzaprine was more likely to lead to global symptom improvement by day 10 of treatment, with an impressive NNT of 3. Unfortunately, it was also much more likely to cause dizziness, nausea, drowsiness, and dry mouth, with a NNH of 4 for any adverse effect. In other words, participants were almost as likely to feel worse on the drug as they were to feel better. Further, most trials did not use intention-to-treat analysis or had other important flaws in quality, making even this marginal benefit uncertain.
The second article is a POEM that summarized a randomized trial comparing functional outcomes in adults with acute, nontraumatic, nonradicular low back pain who received naproxen plus placebo, naproxen plus cyclobenzaprine, or naproxen plus oxycodone/acetaminophen for 10 days. Research associates blinded to treatment arm assignment assessed participants for pain and functional outcomes in telephone interviews conducted at 7 days and 3 months of follow-up. There were no statistical differences between groups in either outcome at either time point. However, the NNH for adverse effects was 7.8 for cyclobenzaprine and 5.3 for oxycodone/acetaminophen.
Based on this information, I plan to prescribe naproxen alone for most patients with acute low back pain and no contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs); reserve cyclobenzaprine for patients who can't use NSAIDs; and prescribe oxycodone/acetaminophen only in patients who can't tolerate NSAIDs or cyclobenzaprine.
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This post first appeared on the AFP Community Blog.
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Medicine
For acute low back pain, naproxen alone works best
In urgent and primary care settings, when a patient requests medication for acute low back pain without radicular symptoms, I typically prescribe naproxen and cyclobenzaprine, adding oxycodone/acetaminophen if the pain seems especially severe. But two recent articles in American Family Physician will likely lead me to change my practice.
The first article is a Medicine by the Numbers that reviewed the number needed to treat (NNT) and number needed to harm (NNH) from a pooled analysis of trials evaluating cyclobenzaprine for low back pain. Compared to placebo, cyclobenzaprine was more likely to lead to global symptom improvement by day 10 of treatment, with an impressive NNT of 3. Unfortunately, it was also much more likely to cause dizziness, nausea, drowsiness, and dry mouth, with a NNH of 4 for any adverse effect. In other words, participants were almost as likely to feel worse on the drug as they were to feel better. Further, most trials did not use intention-to-treat analysis or had other important flaws in quality, making even this marginal benefit uncertain.
The second article is a POEM that summarized a randomized trial comparing functional outcomes in adults with acute, nontraumatic, nonradicular low back pain who received naproxen plus placebo, naproxen plus cyclobenzaprine, or naproxen plus oxycodone/acetaminophen for 10 days. Research associates blinded to treatment arm assignment assessed participants for pain and functional outcomes in telephone interviews conducted at 7 days and 3 months of follow-up. There were no statistical differences between groups in either outcome at either time point. However, the NNH for adverse effects was 7.8 for cyclobenzaprine and 5.3 for oxycodone/acetaminophen.
Based on this information, I plan to prescribe naproxen alone for most patients with acute low back pain and no contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs); reserve cyclobenzaprine for patients who can't use NSAIDs; and prescribe oxycodone/acetaminophen only in patients who can't tolerate NSAIDs or cyclobenzaprine.
**
This post first appeared on the AFP Community Blog.
- Medical Interventions We Shouldn't Be Getting: Issues Of Cost, Health, And Equity
Many of us are concerned about the cost of medical care, particularly in the US. We are also concerned about the care that we, ourselves or our families and friends receive. We want the diagnostic tests and treatments we get to be likely to benefit us...
- The Problem Of Pain
My patients lie to me every day. Some tell me that they have been taking their medications regularly when they haven't. Some say that they have been eating a healthy diet and exercising for at least 30 minutes every day and don't know where the...
- Misconceptions About Palliative Care Are Common
In inpatient settings, family physicians frequently care for patients with progressive, incurable conditions that cause severe pain. Interventions aimed at slowing the progress of a disease often add to patients' physical distress; therefore, pharmacologic...
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Last week, the family medicine residency inpatient service that I supervise admitted several patients from the emergency department with acute chest pain that had resolved. Most of them had no history of cardiovascular disease, but were deemed to have...
- Extra Diagnostic Tests Don't Reassure: Another Reason To Choose Wisely
Steering patients away from unnecessary and potentially harmful tests and treatments is an essential component of high-quality primary care. The March 1st issue of American Family Physician includes two articles that reflect this philosophy as embodied...