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#143 Acute Back Pain: Is Cyclobenzaprine a reasonable option?


CLINICAL QUESTION
QUESTION CLINIQUE
What is the effectiveness of cyclobenzaprine for acute back pain?


BOTTOM LINE
RÉSULTAT FINAL
Cyclobenzaprine provides reduced pain and increased global improvement over placebo for one in every 3-9 patients in the first week. Cyclobenzaprine is as good or better than diazepam. Cyclobenzaprine 5 mg TID (half-pill) is as effective as 10 mg TID with less somnolence



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EVIDENCE
DONNÉES PROBANTES
  • Systematic reviews and newer Randomized Controlled Trials (RCTs): 
    • Non-benzodiazepine muscle relaxants versus placebo: Three systematic reviews (9-46 RCTs, 820-5,401 patients), differences statistically significant:1-3 
      • Pain: ~12 points lower on 100 point Visual Analogue Scale at 10 days.1 
      • Pain: Attaining undefined ‘pain reduction Number Needed to Treat (NNT)=4-7 at 2-7 days.2 
      • Global efficacy:2 Attaining undefined ‘target’ NNT=4 at days 2-4.  
    • Cyclobenzaprine versus placebo:  
      • One systematic review (14 RCTs, 3,023 patients):4 
        • Global improvement, NNT=3 at ~10 days. 
      • Two publications with two RCTs each, we pooled and did statistics: 
        • Dosing (1,389 patients):5 
          • Backache relief: 50cyclobenzaprine 5 mg TID versus 38% placebo at seven days, NNT=9 (p<0.001).  
            • No difference: 5 mg versus 10 mg or 2.5 mg versus placebo. 
        • Extended or Immediate Release504 patients.6 
          • No difference: Extended release 30 mg OD versus immediate release  10 mg TID.  
    • Cyclobenzaprine plus ibuprofen, three RCTs:7-9 
      • Largest (867 patients): No benefit to adding ibuprofen.7 
      • Two small studies of back/neck strain, (77 and 61 patients): Too underpowered to find differences.8,9 
CONTEXT:  
  • Concerns: Most trials industry sponsored;4 small samples; short duration, poorly-defined targets; unclear if clinically meaningful cut-offs.   
  • No difference in efficacy between the different muscle relaxants although cyclobenzaprine more consistently evaluated.3 
  • Other medications:  
    • Cyclobenzaprine better or equivalent to diazepam.3 
    • Other direct comparisons are lacking but versus placebo: 
      • Acetaminophen: No effect on back pain.10  
      • NSAIDs: NNT=11 for global improvement.11 
  • Adverse events: Dose related somnolence and dry mouth:5 
    • Any somnolence:5 10placebo, 29% for 5 mg TID, 38% for 10 mg TID. 
      • 10mg TID caused more somnolence than 5mg TID, Number Needed to Harm (NNH)=12. 
    • Discontinuation from somnolence:5 0.8placebo, 2.5for 5 mg TID, 5.2% for  10 mg TID. 
  • Guidelines recommend cyclobenzaprine for the treatment of acute low back pain.12 


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Author(s)
Auteur(s)
  • Emelie Braschi PhD MD
  • G. Michael Allan MD CCFP

1. Machado LA, Kamper SJ, Herbert RD. Rheumatology (Oxford). 2009; 48:520-7.

2. Van Tulder MW, Touray T, Furlan AD. Cochrane Database System Rev. 2003; 4:CD004252.

3. Chou R, Peterson K, Helfand M. J Pain Symptom Manage. 2004; 28:140-75.

4. Browning R, Jackson JL, O'Malley PG. Arch Intern Med. 2001; 161:1613-20.

5. Borenstein DG, Korn S. Clin Ther. 2003; 25:1056-73.

6. Malanga GA, Ruoff GE, Weil AJ, et al. Curr Med Res Opin. 2009; 25:1179-96.

7. Childers MK, Borenstein D, Brown RL, et al. Curr Med Res Opin. 2005; 21:1485-93.

8. Turturro MA, Frater CR, D'Amico FJ. Ann Emerg Med. 2003; 41:818-26.

9. Khwaja SM, Minnerop M, Singer AJ. CJEM. 2010; 12:39-44.

10. Williams CM, Maher CG, Latimer J, et al. Lancet. 2014; 384:1586-96.

11. Roelofs PD, Deyo RA, Koes BW, et al. Cochrane Database Syst Rev. 2008; 1:CD000396.

12. Toward Optimized Practice guideline: Evidence-Informed Primary Care Management of Low Back Pain. 2011. Available at: http://www.topalbertadoctors.org/download/572/LBPGUIDELINESNov25.pdf?_20150414142359. (Last accessed April 14, 2015).

Authors do not have any conflicts to disclose.