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Mathieson S, Kasch R, Maher CG, et al. Combination Drug Therapy for the Management of Low Back Pain and Sciatica: Systematic Review and Meta-Analysis. J Pain. 2019 Jan;20(1):1-15. doi: 10.1016/j.jpain.2018.06.005. Epub 2018 Jul 3. (Systematic review)
Abstract

Combining medicines may give greater pain relief and/or improved tolerability. We conducted a systematic review to investigate the effects of combination drug therapy in patients with low back pain and/or sciatica on pain, disability, and adverse events. Databases and trial registers were searched from inception to July 27, 2017, for randomized trials of (sub)acute or chronic back pain or sciatica participants that were administered combination drug therapy compared with monotherapy or placebo. Of the 27 studies included, most combinations (21 of 23) consisted of single trials. Most combinations had no or small effect on pain and disability. A clinically important difference was found in one combination, buprenorphine plus pregabalin versus buprenorphine for chronic back pain at immediate (mean difference = -23.30; 95% confidence interval?=?-27.68 to -18.92) and short (mean difference?=?-27.60; 95% confidence interval?=?-31.70 to -23.50) terms; however, the quality of evidence was low. There was no statistically significant increased risk of serious adverse events. When the risk of adverse events was statistically significant, it favored monotherapy or placebo. There is no clear evidence to support any combination drug therapy for the management of low back pain and sciatica due to the limited number of studies and overall low quality of evidence. Perspective: Combining medicines may give greater pain relief and/or improved tolerability compared with single-ingredient medicines. However, the lack of studies and overall low quality of evidence limit the recommendation of combination drug therapy for the management of low back pain and sciatica.

Ratings
Discipline Area Score
Physician 4 / 7
Comments from MORE raters

Physician rater

The question of pain control using single or combination treatment is an important one. The evidence of the meta analysis does not warrant a change in practice one way or another. Therefore, decisions should be made through conversations with patients on a periodic basis and treatments should be given accordingly.

Physician rater

Most of the studies regard opioids or related drugs. As a clinician, I am more interested in combination with paracetamol; thus, I am interested in only one study (diclofenac with pcm). This is the kind of combination we prefer at the moment as there are so many problems with opioid addiction. I miss this point in the discussion.

Physician rater

Although this systematic review reports the present status on how to manage low back pain and sciatic neuralgia, its evidence levels are not good and we can not get any conclusion on this issue. Therefore, this paper does not add any new clinically important information.

Physician rater

"There is no clear evidence to support any combination drug therapy for the management of low back pain and sciatica due to the limited number of studies and overall low quality of evidence"; this basically sums it up. There may yet BE a combination that will provide better outcomes, but so far no data have been convincing enough to make it standard of practice.
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