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RCT – Ibuprofen + Acetaminophen for Low Back Pain

January 8, 2020

Written by Clay Smith

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There was no difference in disability or pain one week after discharge in patients with acute low back pain with ibuprofen + placebo vs. ibuprofen + acetaminophen.

Why does this matter?
In an effort to reduce unnecessary opiate prescribing, alternative modes of pain control are needed. Prior studies have shown ibuprofen + acetaminophen was as effective as an opiate for acute sprains and fractures. How would this combination fare in garden variety back pain? Bear in mind, 70% of back pain patients who come to the ED are still taking analgesics a week later and about half at 3 months.

Back pain is a pain in the neck
In this RCT, patients with non-traumatic, non-radicular back pain were randomized to either ibuprofen + placebo or ibuprofen + acetaminophen. The ibuprofen dose was 600mg; acetaminophen was 500-1000mg every 6 hours. For the primary outcome of disability (Roland-Morris Disability Questionnaire), there was no difference at one week. For a secondary outcome of moderate to severe pain, there was also no difference at one week. There was also no difference in the secondary outcomes of severity of pain, frequency of pain, or use of analgesics in the previous day at either 24 or 48 hours. My take away is that options for acute low back pain are limited. NSAIDs are somewhat helpful. Acetaminophen monotherapy or add-on therapy does not help. Benzodiazepines may make matters worse; other muscle relaxers have not been shown to help; opiates are no help; steroids may help radicular pain.

Ibuprofen + acetaminophen versus ibuprofen alone for acute low back pain. An ED-based randomized study. Acad Emerg Med. 2019 Dec 6. doi: 10.1111/acem.13898. [Epub ahead of print]

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