The authors’ bottom line:
“Adding baclofen, metaxalone, or tizanidine to ibuprofen does not appear to improve functioning or pain any more than placebo plus ibuprofen by 1 week after an ED visit for acute low back pain.”
There were 320 patients with atraumatic back pain randomized to one of four arms in a 1:1:1:1 manner at two urban Emergency Departments, with follow-up one week later. As noted above, the differences in improvement on the Roland-Morris Disability Questionnaire were similarly scattershot across groups. The waterfall graph probably shows this best:
Notes:
- The prescribed dose of ibuprofen was only 600mg every eight hours. I’m more a 500mg naproxen twice daily sort of guy, but this wouldn’t necessarily obscure differences between groups.
- Half of patients continued to complain of back pain at seven days, including a third for whom it was moderate or severe.
- Adverse events were rare in all groups.
Pretty dismal and disappointing, as so many of our patients in the ED are coming in because they’re already taking some over-the-counter analgesic without perceived relief. There is clearly an unmet need for something to fill the void, hence our attempted use of all these unproven adjuncts. Unfortunately, these folks are stuck – it’s going to be 2-3 days until they will be able to return to their usual activities, if not more, and none of these are adding any value.
“A Randomized, Placebo-Controlled Trial of Ibuprofen Plus Metaxalone, Tizanidine, or Baclofen for Acute Low Back Pain”
2-3 days, or weeks?
Agree – 2-3 days is different than the primary outcome of most trials.
For example, from the wayback machine: https://www.emlitofnote.com/?p=3215
Placebo vs. Percocet vs. cyclobenzaprine – everyone is gradually getting better at 1 week or 3 months, but the secondary trends all seem to favor preferring the opiate intervention.
I’m absolutely not opposed to a 2-3 day supply of opiates for appropriately selected acute back pain patients, although, of course, I wish we had better options.
The trial that is missing, so far, is opiates for *acute* back pain. Everyone loves to hate them, but I have yet to see any data regarding their use in the first 2-3 days of an acute episode.