Gabapentinoids Seem to Offer Little Benefit, Substantial Risks in Low Back Pain — Physician’s First Watch

Medical News |
August 16, 2017

Gabapentinoids Seem to Offer Little Benefit, Substantial Risks in Low Back Pain

By Amy Orciari Herman

Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM

Gabapentinoids, increasingly used for chronic low back pain, offer little benefit and carry substantial risks in this setting, finds a systematic review in PLOS Medicine.

Researchers examined eight randomized trials in which gabapentin or pregabalin was compared with active or inactive treatments in adults with low back pain lasting at least 3 months. Doses ranged from 300–3600 mg/day for gabapentin and 100–600 mg/day for pregabalin. Among the findings:

  • Gabapentin was associated with a small reduction in pain compared with placebo (very-low-quality evidence).

  • Pregabalin was less effective than comparator treatments (e.g., amitriptyline, celecoxib) in relieving pain (very-low-quality evidence).

  • Gabapentin was associated with increased risks for dizziness (number needed to harm, 7), fatigue (NNH, 8), mental difficulties (6), and visual disturbances (6).

  • Pregabalin was associated with elevated risk for dizziness (NNH, 11).

The researchers conclude, "Given the lack of efficacy, risks, and costs associated, the use of gabapentinoids for [low back pain] merits caution."

Reader Comments (3)

YiZhong Zhuang Fellow-In-Training, Neurology, Academic Hospital

Three sessions a week of 2 hours Yoga, and MBSR have each been shown to be efficacious in low back pain without any side effects and are low to no cost. Far better than opioids and NSAIDs, and likely better than gabapentinoids. Also, they can be used simultaneously and as add-on to pharmacotherapy.

Minzer, Benito.MD and profesor at the UNC Argentina Physician, Cardiology, Hospital

To treat lumbar paín there are a lot of methods. I'm sending my patients to be treated with RPG (global postural repositioning). And it working very good.

ROGER FELIX Physician, Family Medicine/General Practice, outpatient clinic

The studies above are all labeled "very low-quality evidence." in 2009, an excellent Pharm. D. pain consultant of mine strongly recommended gabapentin --high-dose if necessary -- as an adjunct to opioid therapy in lumbar disc disease with radiculopathy. I listened to him, and still find many cases where gabapentin adds a lot of pain relief for a patient. and without side effects. In some cases my patients have been able to minimize or even discontinue opioids in favor of gabapentin. Well, how about being able to minimize opioid risk -- does that count as efficacy? I just caution the patient that s/he may become drowsy or dizzy on gabapentin, to start it at HS, and to d/c it if adverse effects are significant and outweigh pain relief. The idea that I should abandon this useful medication and just keep dialing up the opioids instead doesn't seem helpful to me. Everybody tells us that nothing works, including opioids. So what -- physical therapy? Most of my poor patients can't afford the co-pays, and many of them say that PT makes them worse. Instead of constantly publishing guidelines that encourage us to tell our chronic pain patients "nothing works, go home and suffer in silence," let's acknowledge that pain management is an art as well as a science and let us work with whatever we have left while we jeopardize our livelihood and retirement plans by prescribing opioids so that our patients can have their suffering relieved.

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