Medication Summary
Various medications have been used in the treatment of LBP from DDD, to include acetaminophen, NSAIDs, muscle relaxants, opioid analgesics, oral corticosteroids, and antidepressants. No standard doses have been established for oral prednisone in the treatment of lumbar radicular pain. Before prescribing these medications, the physician should be aware of the contraindications, common adverse effects, and mode of action of each agent.
Nonsteroidal anti-inflammatory drugs
Class Summary
Offer additional anti-inflammatory effects compared with acetaminophen. The dose to produce anti-inflammatory effects differs substantially from that for analgesic effects. Most NSAIDs achieve only analgesic effects because the dose prescribed is too small and too infrequent to produce an anti-inflammatory effect. Risks are associated with NSAIDs, especially in the elderly population and in those with a history of peptic ulcer disease, hypertension, or renal insufficiency. Newer generation NSAIDs selectively interact with the COX-2 receptors and have a lower gastrointestinal risk. Prolonged use of these medications generally is not recommended for most patients with low back problems.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and by inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Analgesics
Class Summary
The use of opioids in the treatment of LBP should be limited to pain that is unresponsive to alternative medication. Opioids can be prescribed for acute disc herniation or other back injury to facilitate participation in an active rehabilitation program. They should be used on a defined dosing schedule and not on an as-needed basis. In addition, adequate baseline dose should be established to achieve analgesia. The use of nonopioid analgesics, such as tramadol, also is an option.
Oxycodone (OxyContin)
Drug combination indicated for the relief of moderate to severe pain.
Tramadol (Ultram)
Inhibits ascending pain pathways, altering perception of and response to pain. Inhibits reuptake of norepinephrine and serotonin.
Muscle relaxants
Class Summary
Medications categorized as muscle relaxants may be helpful in some patients with LBP and seem to have additional beneficial effects when used in conjunction with NSAIDs. Muscle relaxants can be used as short-term adjunctive medications, and they should be taken at bedtime to take advantage of their sedating effects.
Cyclobenzaprine (Flexeril)
Skeletal muscle relaxant that acts centrally and reduces motor activity of tonic somatic origins influencing both alpha and gamma motor neurons. Structurally related to tricyclic antidepressants and thus carries some of their same liabilities.
Oral steroids
Class Summary
Potent anti-inflammatory medications represent theoretically useful agents in the treatment of patients with radiculopathy due to local inflammation resulting from disc injury or herniation. No standard doses have been established for oral prednisone in the treatment of lumbar radicular pain.
Prednisone (Deltasone, Sterapred, Orasone)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Antidepressants
Class Summary
Tricyclic antidepressants (TCAs) have been well studied and supported as useful analgesics in patients with pain of neurogenic origin. TCAs also can be helpful as adjuncts for pain and sleep if used at bedtime. Initial doses should be low, and subsequent doses can be slowly increased to minimize adverse effects.
Amitriptyline (Elavil)
By inhibiting reuptake of serotonin and/or norepinephrine in presynaptic neuronal membrane, may increase the synaptic concentration of serotonin in the CNS.
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Degenerative lumbar disc disease in the mature athlete. Degenerative changes of the lumbar spine, including decreased signal intensity and disc bulging at the L-3/4, L-4/5 and L-5/S-1 discs.
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Degenerative lumbar disc disease in the mature athlete. The process of disc degeneration following internal disc disruption and herniation.
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Degenerative lumbar disc disease in the mature athlete. The various forces placed upon the discs of the lumbarspine that can result in degenerative changes.
