Update to Chronic Pain: Low Back Pain

30 Oct Update to Chronic Pain: Low Back Pain

TreatGx users now have access to the updated Chronic Pain – Low Back Pain treatment algorithm. A key feature of this update is being able to view all medication options at-a-glance. In addition to displaying personalized dosing options based on kidney function, liver function, drug-drug interactions, medical history, and pharmacogenetics (whether available or not), and continuing to provide guidance on gastroprotection in patients at high risk of gastrointestinal complications with NSAID use, the update includes new features to help personalize medication therapy: 

• Addition of the most common side effects for all medications 
• Addition of COX-selectivity profiles for each NSAID 
• Several additional medication options: low-dose capsaicin transdermal patch, additional NSAID options (diflunisal, etodolac, indomethacin, meloxicam, nabumetone, piroxicam, and sulindac), and additional opioid options for the US (hydrocodone, oxymorphone). 
• Guidance on cautious opioid dosing from the Canadian Guideline for Opioids for Chronic Non-Cancer Pain [1] and the CDC Guideline for Prescribing Opioids for Chronic Pain [2], and summary of evidence from the 2018 trial on Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. [3] 
• Guidance on non-pharmacological therapies for chronic low back pain, which should be implemented in all patients alongside any medications.

Several clinical guidelines for chronic low back pain were reviewed to provide updated medication options: the American College of Physicians 2017 Clinical Practice Guideline Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain [4]; the North American Spine Society 2020 Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain [5]; the Department of Veterans Affairs/Department of Defense 2017 VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain [6]; and the National Institute for Health and Care Excellence 2016 Guideline on Low Back Pain and Sciatica [7]. 

Based on the clinical guideline and evidence review, several medications were also removed as their routine use is no longer supported by the published evidence: TCAs (amitriptyline, desipramine, nortriptyline), acetaminophen, and acetaminophen/opioid combinations (acetaminophen/codeine, acetaminophen/oxycodone, acetaminophen/tramadol). 

References: 

1.Busse J: The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. In: National Pain Center. Hamilton, ON: McMaster University; 2017. 

2.Dowell D HT, Chou R: CDC Guideline for Prescribing Opioids for Chronic Pain. In: National Center for Injury Prevention and Control, CDC. Atlanta, GA; 2016. 

3.Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S: Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. Jama 2018, 319(9):872-882. 

4.Qaseem A, Wilt TJ, McLean RM, Forciea MA: Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of internal medicine 2017, 166(7):514-530. 

5.North American Spine Society Evidence-Based Guideline Development Committee: Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. In: North American Spine Society. Burr Ridge, IL; 2020. 

6.Department of Veterans Affairs/Department of Defense: VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain. 2017. 

7.National Institute for Health and Care Excellence: Low back pain and sciatica in over 16s [NICE Guideline NG59] – Full guideline. In: National Institute for Health and Care Excellence (UK). London; 2016.