Published: 10 February 2016
Authors: Enthoven WTM, Roelofs PDDM, Deyo RA, van Tulder MW, Koes BW
Primary Review Group: Back and Neck Group
Review question
We assessed the evidence regarding the effect of non-steroidal anti-inflammatory drugs (NSAIDs) among people with chronic low back pain. NSAIDs were compared to placebo, other NSAIDs, other drugs or other kinds of treatment.
Background
Chronic low back pain is common and causes pain and disability. NSAIDs are often used to treat people with chronic low back pain and are available both over-the-counter and on prescription in different types and chemical entities.
Study characteristics
We collected all published randomized controlled trials evaluating the efficacy of NSAIDs until 24 June 2015. We included 13 trials which compared NSAIDs withplacebo, other NSAIDs, other drugs or other treatment in people with chronic low back pain. Six trials compared NSAIDs with placebo, and included 1354 participants in total. Follow-up was between nine days and 16 weeks.
Key results
NSAIDs reduced pain and disability in people with chronic low back pain compared to placebo. However, the differences were small: 3.3 points on a 100-point scale for pain intensity. Regarding disability, people receiving NSAIDs scored 0.9 points better on a 0 to 24 disability scale. The number of adverse events was not significantly different between the people receiving NSAIDs and people receiving placebo, but larger studies of longer duration would be needed to identify rare or delayed adverse events, important drug interactions and adverse events occurring with prolonged use.
Different types of NSAIDs did not show significantly different effects. Three of the 13 included studies compared two different types of NSAIDs and none found any differences.
NSAIDs were also compared to other drug types: paracetamol, tramadol and pregabalin. There were no differences found between NSAIDs and paracetamol and pregabalin in either effect or adverse events. A single study comparing celecoxib with tramadol showed a better global improvement in peoples using celecoxib.
One trial compared NSAIDs with ‘home-based exercise’. Regarding disability, people who did exercise improved more than people receiving NSAIDs, but pain scores were not statistically different.
Quality of the evidence
There was low quality evidence that NSAIDs are slightly more effective than placeboin chronic low back pain. The magnitude of the difference was small, and when we only accounted for trials of higher quality, these differences reduced.
Six of the 13 included RCTs showed that NSAIDs are more effective thanplacebo regarding pain intensity. NSAIDs are slightly more effective thanplacebo regarding disability. However, the magnitude of the effects is small, and the level of evidence was low. When we only included RCTs at low risk ofbias, differences in effect between NSAIDs and placebo were reduced. We identified no difference in efficacy between different NSAID types, including selective versus non-selective NSAIDs. Due to inclusion of RCTs only, the relatively small sample sizes and relatively short follow-up in most included trials, we cannot make firm statements about the occurrence of adverse events or whether NSAIDs are safe for long-term use.