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Enke O, New HA, New CH, et al. Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. CMAJ. 2018 Jul 3;190(26):E786-E793. doi: 10.1503/cmaj.171333.
Ratings
Discipline Area Score
Physician 6 / 7
Abstract

BACKGROUND: The use of anticonvulsants (e.g., gabapentin, pregabalin) to treat low back pain has increased substantially in recent years despite limited supporting evidence. We aimed to determine the efficacy and tolerability of anticonvulsants in the treatment of low back pain and lumbar radicular pain compared with placebo.

METHODS: A search was conducted in 5 databases for studies comparing an anticonvulsant to placebo in patients with nonspecific low back pain, sciatica or neurogenic claudication of any duration. The outcomes were self-reported pain, disability and adverse events. Risk of bias was assessed using the Physiotherapy Evidence Database (PEDro) scale, and quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Data were pooled and treatment effects were quantified using mean differences for continuous and risk ratios for dichotomous outcomes.

RESULTS: Nine trials compared topiramate, gabapentin or pregabalin to placebo in 859 unique participants. Fourteen of 15 comparisons found anticonvulsants were not effective to reduce pain or disability in low back pain or lumbar radicular pain; for example, there was high-quality evidence of no effect of gabapentinoids versus placebo on chronic low back pain in the short term (pooled mean difference [MD] -0.0, 95% confidence interval [CI] -0.8 to 0.7) or for lumbar radicular pain in the immediate term (pooled MD -0.1, 95% CI -0.7 to 0.5). The lack of efficacy is accompanied by increased risk of adverse events from use of gabapentinoids, for which the level of evidence is high.

INTERPRETATION: There is moderate- to high-quality evidence that anticonvulsants are ineffective for treatment of low back pain or lumbar radicular pain. There is high-quality evidence that gabapentinoids have a higher risk for adverse events.

PROTOCOL REGISTRATION: PROSPERO-CRD42016046363.

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Comments from MORE raters

Physician rater

This is more reinforcement to the signal that anticonvulsants don't work either, and have side effects. I hate back pain - nothing works or is safe to use, yet there is pressure to order medications, therapies, tests, consultations that are not proven to help from suffering patients and/or their impatient disability insurers.

Physician rater

If GABAergic agents don't work for chronic back pain, and chronic opiates don't work for chronic back pain, what works?

Physician rater

This is useful information for doctors who still prescribe anticonvulsants in the treatment of low back pain and lumbar radicular pain.

Physician rater

Opioids have known risks and limited benefit in chronic back pain. Even though we are desperate for safer alternatives, we should not desperately begin to use alternative with unknown benefits and there own risks!
Comments from PAIN+ CPN subscribers

Dr. Brian Budenholzer (7/12/2018 5:43 PM)

To some extent, I agree with the first MORE commentator. But as a family physician, and an intermittent back pain sufferer, I would say [almost] nothing works so doing [almost] nothing helps. Though not everyone improves with time, many, perhaps most do. So, do no harm, stay (mostly) out of the way, and let (most) people get better.