In patients with chronic back pain, are NSAIDs more effective for pain reduction than acetaminophen?

Ameta-analysis of 13 randomized control trial (RCT)’s (N51,354) evaluated NSAIDs for chronic low back pain (LBP) using decreased pain and improved function as the primary outcomes. Researchers enrolled adult patients treated for nonspecific LBP (NSLBP) for . 12 weeks.NSLBPwasdefinedasbackpainwithout identified etiologic disease or condition. Pain was measured using a 0to 100-mm visual analog scale (VAS). Six trials involving 1,354 patients compared NSAIDs (moderate doses of various selective or nonselective NSAIDs) and demonstrated a 6.97-mm greater mean decrease in pain intensity from baseline over placebo at nine to 112 days (95% CI, 3.10–10.74). The quality of included studies was low, and the effect was no longer statistically significant after exclusion of three trials at high risk of bias. The relative risk of adverse effects of NSAIDs compared with placebo was not significant (risk ratio [RR], 1.04; 95% CI, 0.92–1.17, N51,354); due to small sample sizes and maximum 16-week follow-up interval, it is likely that adverse effects were underestimated. A 2017 meta-analysis including two randomized trials (n51,785) explored the efficacy of paracetamol (4 g/d) versus placebo at 12 weeks for improvement in pain and disability in patients with acute (,six weeks) NSLBP. Pain was measured based on a 0 to 100 VAS. Disability was measured using the Roland Morris Disability Questionnaire, scores 0 to 24, with higher scores indicating more severe disability. No difference was observed between paracetamol and placebo for pain at one week (mean difference [MD], 1.49; 95% CI, –1.30 to 4.28), two weeks (MD, 1.00; 95% CI, –1.70 to 3.70), four weeks (MD, 0.49; 95% CI, –1.99 to 2.97), and 12 weeks (MD, –0.50; 95% CI, –2.92 to 1.92). Also, no difference was observed between paracetamol and placebo for disability at one week (MD, –0.45; 95%CI, –1.15 to 0.25), twoweeks (MD, 0.0; 95%, CI –0.65 to 0.65), four weeks (MD, 0.05; 95%CI, –0.50 to 0.60), and 12weeks (MD, 0.10; 95%CI, –0.39 to 0.59). No differences were foundbetween the groups in total adverse events (RR, 1.07; 95% CI, 0.86–1.33) or serious adverse events (RR, 0.90; 95% CI, 0.30–2.67). A 2016 RCT compared celecoxib with acetaminophen in 50 patients with chronic NSLBP. Researchers enrolled adult patients with chronic NSLBP (lasting.three months) and scores . four on a 0to 10-point VAS. Patients were randomized into two groups, one treated with celecoxib 200 mg twice daily for four weeks and the other receiving acetaminophen 500 mg twice daily for four weeks. The study evaluated preand posttreatment scores on total back pain (TBP) and nocturnal back pain (NBP) using 0 to 10VAS.Disability was assessed using the Oswestry Disability Index (ODI), a 10-item disability questionnairewith scores 0 to 100with 0 being no disability and 100 being severe, and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), a validated questionnaire for ankylosing spondylitis disability using a scale of 0 to 10 with 10 being severe. The celecoxib group showed a greater decrease in all measures compared with the acetaminophen group as illustrated in preand posttreatment delta changes (–2 vs –0.5, P5.04 for TBP; –5 vs 0, P5.008 for ODI; –1.1 vs –0.4, P5.03 for BASDAI; –1 vs 0, P5.01 for NBP). More patients experienced significant reduction in back pain (defined as$50% reduction in pain or disability) in the celecoxib group versus the acetaminophen group (ODI: 34.8% vs 4.5%; P5.02; NBP: 41.7% vs 9.1%; P5.02; TBP: 33.3% vs 9.1%; P5.07; BASDAI: 30.4% vs 9.1%; P5.13). No adverse reactions were reported (those with prior adverse reactions had been ineligible). One limitation of the study was that acetaminophen was dosed under the maximum dose, whereas celecoxib was dosed at the maximum dose for the study. A clinical practice guideline from theAmericanCollege of Physicians was developed using systematic reviews, which explored pharmacologic interventions for acute, subacute, and chronic LBP from 2007 to 2015. This guideline, based on moderate-quality evidence, had a weak recommendation that patients with chronic LBP