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Title: | Comparative effectiveness and safety of analgesic medicines for adults with non-specific acute low back pain: systematic review and network meta-analysis |
Authors: | Wewege, MA Bagg, MK Jones, MD Ferraro, MC Cashin, AG Rizzo, RRN Leake, HB Hagstrom, AD Sharma, S McLachlan, AJ Maher, CG Day, R Wand, BM O'Connell, NE Nikolakopolou, A Schabrun, S Gustin, SM McAuley, JH |
Issue Date: | 22-Mar-2023 |
Publisher: | BMJ Publishing Group |
Citation: | Wewege, M.A. et al. (2023) 'Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain: systematic review and network meta-analysis' British Medical Journal, 380 (8376), pp.1 - 15. doi: 10.1136/bmj.p708. |
Abstract: | Objective: To evaluate the comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain. Design: Systematic review and network meta-analysis. Data sources: Medline, PubMed, Embase, CINAHL, CENTRAL, ClinicalTrials.gov, clinicialtrialsregister.eu, and World Health Organization’s International Clinical Trials Registry Platform from database inception to 20 February 2022. Eligibility criteria for study selection: Randomised controlled trials of analgesic medicines (eg, non-steroidal anti-inflammatory drugs, paracetamol, opioids, anti-convulsant drugs, skeletal muscle relaxants, or corticosteroids) compared with another analgesic medicine, placebo, or no treatment. Adults (≥18 years) who reported acute non-specific low back pain (for less than six weeks). Data extraction and synthesis: Primary outcomes were low back pain intensity (0-100 scale) at end of treatment and safety (number of participants who reported any adverse event during treatment). Secondary outcomes were low back specific function, serious adverse events, and discontinuation from treatment. Two reviewers independently identified studies, extracted data, and assessed risk of bias. A random effects network meta-analysis was done and confidence was evaluated by the Confidence in Network Meta-Analysis method. Results: 98 randomised controlled trials (15 134 participants, 49% women) included 69 different medicines or combinations. Low or very low confidence was noted in evidence for reduced pain intensity after treatment with tolperisone (mean difference −26.1 (95% confidence intervals −34.0 to −18.2)), aceclofenac plus tizanidine (−26.1 (−38.5 to −13.6)), pregabalin (−24.7 (−34.6 to −14.7)), and 14 other medicines compared with placebo. Low or very low confidence was noted for no difference between the effects of several of these medicines. Increased adverse events had moderate to very low confidence with tramadol (risk ratio 2.6 (95% confidence interval 1.5 to 4.5)), paracetamol plus sustained release tramadol (2.4 (1.5 to 3.8)), baclofen (2.3 (1.5 to 3.4)), and paracetamol plus tramadol (2.1 (1.3 to 3.4)) compared with placebo. These medicines could increase the risk of adverse events compared with other medicines with moderate to low confidence. Moderate to low confidence was also noted for secondary outcomes and secondary analysis of medicine classes. Conclusions: The comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain are uncertain. Until higher quality randomised controlled trials of head-to-head comparisons are published, clinicians and patients are recommended to take a cautious approach to manage acute non-specific low back pain with analgesic medicines. Systematic review registration: PROSPERO CRD42019145257 |
Description: | Data availability statement: League tables with estimates and confidence for all comparisons are available in spreadsheets available on the Open Science Framework (https://osf.io/kduq3). The dataset used and analysed during this study and the accompanying code are available from the corresponding author on reasonable request. |
URI: | https://bura.brunel.ac.uk/handle/2438/26214 |
DOI: | https://doi.org/10.1136/bmj.p708 |
ISSN: | 1759-2151 |
Other Identifiers: | ORCiD: Michael A. Wewege https://orcid.org/0000-0002-3283-2149 ORCiD: Matthew K. Bagg https://orcid.org/0000-0002-4812-3814 ORCiD: Matthew D. Jones https://orcid.org/0000-0002-5534-755X ORCiD: Michael C. Ferraro https://orcid.org/0000-0003-0563-1832 ORCiD: Aidan G. Cashin https://orcid.org/0000-0003-4190-7912 ORCiD: Rodrigo R.N. Rizzo https://orcid.org/0000-0002-9624-6210 ORCiD: Hayley B. Leake https://orcid.org/0000-0002-0241-873X ORCiD: Amanda D. Hagstrom https://orcid.org/0000-0002-8036-9216 ORCiD: Saurab Sharma https://orcid.org/0000-0002-9817-5372 ORCiD: Andrew J. McLachlan https://orcid.org/0000-0003-4674-0242 ORCiD: Christopher G. Maher https://orcid.org/0000-0002-1628-7857 ORCiD: Richard Day https://orcid.org/0000-0002-6045-6937 ORCiD: Benedict M. Wand https://orcid.org/0000-0002-0297-0292 ORCiD: Neil E. O’Connell https://orcid.org/0000-0003-1989-4537 ORCiD: Adriani Nikolakopolou https://orcid.org/0000-0001-5884-4319 ORCiD: Siobhan Schabrun https://orcid.org/0000-0002-9083-3107 ORCiD: Sylvia M. Gustin https://orcid.org/0000-0002-9613-9845 ORCiD: James H. McAuley https://orcid.org/0000-0002-0550-828X |
Appears in Collections: | Dept of Health Sciences Research Papers |
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