Drug options for lower back pain are narrowing, so research doctors are calling for more use of physical treatment
Acetaminophen - also known
as paracetamol and marketed under brand names such as Mapap, Panadol and
Tylenol - is not effective for the treatment of lower back pain and offers
little value for osteoarthritis of the hip or knee, according to a study
published in The BMJ.
The systematic review
and meta-analysis is a synthesis of the research evidence from 13 randomized controlled trials designed to
investigate the safety and efficacy of acetaminophen in the management of
spinal pain - lower back or neck - and osteoarthritis.
The paper concludes
that the widely used painkiller is ineffective against lower back
pain and offers only "minimal short-term benefit"
for people with osteoarthritis of the hip or knee.
The authors of the study call for updates to guidelines that
currently recommend acetaminophen as the first analgesic option.
Lead author Gustavo Machado, of The George Institute for Global
Health in the UK and the University of Sydney in Australia, says:
"Worldwide, paracetamol is the most widely used
over-the-counter medicine for musculoskeletal conditions, so it is important to
reconsider treatment recommendations given this new evidence."
Opinion leaders in the fields of general practice and
rheumatology write in an editorial article about the study that some of its
findings are not surprising.
Professors Christian
Mallen and Elaine Hay say in the same issue of The BMJ that
the new evidence reopens a debate that has already raised questions about the
value of the painkiller. They cite, for example, the changing advice of the
UK's drug-rationing body on the prescription of acetaminophen for
osteoarthritis.
These questions leave "patients and clinicians wondering
what is left that can help to manage these common, painful and highly disabling
conditions."
The editorial urges physical treatments as the way forward,
including exercise. It concludes:
"Ongoing and ever-increasing concerns about
pharmacological management of musculoskeletal pain highlights the importance of
nonpharmacological options, which form the cornerstone of self-management of
spinal pain and osteoarthritis."
The review of the studies comparing acetaminophen against
placebo found "high-quality" evidence that:
§ The
painkiller is ineffective in patients with low back pain for reducing pain
intensity and disability
§ The
analgesic produces a significant but "clinically unimportant" effect
on pain and disability in patients with osteoarthritis.
Similar conclusions were reached in a study published in The Lancet in July of 2014, that acetaminophen "does not ease low-back pain."
The
authors of the present study also found that acetaminophen increased the
likelihood of having abnormal results on liver function tests compared with
placebo.
Machado
explains: "Use of paracetamol for low back pain and osteoarthritis was
also shown to be associated with higher risk of liver toxicity in
patients." The clinical relevance of this, however - the way it affects
patients - remains uncertain, say the authors.
Levels
of overall adverse side effects across the studies were not found to be higher
for the painkiller compared with placebo. However, acetaminophen, like any drug,
is not 100% safe, and the evidence concerning this has developed recently.
Safety issues with acetaminophen
Prof.
David Hunter, an osteoarthritis expert from the University of Sydney but not
one of the authors, cites recent evidence to show that "paracetamol can be
associated with an increasing incidence of mortality, and increased risk of
cardiovascular, gastrointestinal and renal disease in the general adult
population."
We reported earlier this month on the study Prof. Hunter refers
to - it suggested the risks of acetaminophen have been underestimated.
Acetaminophen has been the subject of tighter controls from the
US drug regulator the Food and Drug Administration (FDA) in recent years. Since
2013, new warnings have been included on labels because of the risk of rare but serious skin reactions.
More
recently, the maximum dose of acetaminophen in any tablet or capsule that
combines the drug with an opioid painkiller has been restricted to 325 mg.
Since March 2014, no manufacturer has marketed the treatments with a dose above
this.
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