A new systematic review from the University of Sydney has reported that ibuprofen is no better than placebo for back pain and that risks outweigh any small benefits. http://ard.bmj.com/content/early/2017/01/20/annrheumdis-2016-210597
Non-steroidal anti-inflammatory drugs (NSAIDs, of which ibuprofen is the commonest example) were found to have a clinically significant effect in only 3 out of 14 categories in the analysis, and would improve outcomes over placebo for only 1 in 6 patients. To balance against this, they increased the risk of gastrointestinal reactions by 2.5 times, even over rather short periods of use. The authors pointed out that at present there are no simple pain killers that provide clinically important effects for spinal pain over placebo. This is rather different from NICE’s conclusion: although wary of the side effects they still recommended these drugs, and threw in some opiates for good measure (these are even less effective for back pain).
The Guardian was at pains to point out this does not mean that NSAIDs are ineffective, just that the amount of benefit people feel is not thought to be a clinically important reduction compared to a placebo. Funnily enough this was exactly the reasoning given by NICE for rejecting acupuncture as an option for low back pain.
For a clinician the implication from this study could be that there are relatively few good reasons for starting a patient on NSAIDs for back pain.
However, the situation becomes more complicated when a patient presents with co-morbidities and polypharmacy. The work being done by NHS England Right Care clearly identifies the need to manage medicines and medicines optimisation has been part of health care innovation for a number of years. Where does co-prescribing of NSAIDs fit into this more complex picture and what happens when the risks of NSAIDs are recognised and their use stopped.
How then does the patient manage his or her pain? What support is given across a complex range of co-morbidities that together are reducing overall patient well-being exacerbated by the return of symptoms that might have been partially suppressed by medication?
Might acupuncture be considered when undertaking a medicines review for a patient where the medication includes ‘ineffective’ pain relief?
These questions highlight the challenges created by producing a guideline for a singular ‘simple’ condition.
Royal Pharmaceutical Society. Medicines Optimisation 2015
NICE Guideline on Medicines Optimisation https://www.nice.org.uk/guidance/ng5
2017 NHS England Right Care https://www.england.nhs.uk/rightcare/innovation/mo/