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Ibuprofen, ketorolac, and diclofenac are equivalent for the treatment of acute nonradicular low back pain
Clinical Question
How do ibuprofen, ketorolac, and diclofenac compare for the treatment of acute, nonradicular low back pain in adults?
Bottom line
This study found no differences among ibuprofen, ketorolac, and diclofenac in the primary outcome of overall clinical improvement at 5 days in adults presenting to the emergency department with acute, nonradicular low back pain. Some of the secondary outcomes favored ketorolac, however, leaving open the possibility that ketorolac is superior to ibuprofen and/or diclofenac. As the saying goes, "Absence of proof is not proof of absence." 1b-
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Self-funded or unfunded
Setting: Emergency department
Synopsis
Although nonsteroidal anti-inflammatory drugs (NSAIDs) are the recommended first-line treatment for acute low back pain, there is no clear evidence for recommending one oral NSAID over another. These investigators identified adults, aged 18 to 65 years, who presented to an emergency department with acute low back pain. Eligibility criteria included pain between the lower border of the scapulae and the upper gluteal folds without any radicular symptoms that lasted less than 2 weeks, or a history of direct trauma to the back within the last month. Patients (N = 198) randomly received (concealed allocation assignment) ibuprofen (600 mg every 8 hours, as needed), ketorolac (10 mg every 8 hours, as needed), or diclofenac (50 mg every 8 hours, as needed). Study participants masked to treatment group assignment self-rated overall symptoms, including pain and function, using a validated 24-item low back pain scoring tool. Complete follow-up occurred for 86% of patients at 5 days. Using intention-to-treat analysis, no significant group differences occurred in the primary outcome of an improved pain and function score. A number of secondary outcomes were assessed, some of which significantly favored ketorolac. The investigators, however, appropriately conclude that the current study found no clear evidence to recommend one of these NSAIDs over either of the others.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
NSAIDS for 'acute non-radicular low back-pain'
Overall, this so poor that it should be totally disregarded.
Ibuprofen vs ketorolac vs diclofenac for lower back pain
Not surprised by the result but not sure I am satisfied with the protocol where only 22.8% (198/868) of patients qualified for the study. Based on differenced in the absolute values for the reported outcomes I'm not so sure that the study had sufficient power to detect benefit. The reported confidence intervals are either wide or don't make sense to me. However a difference of 62% vs 80% for little to no pain on day 5 when comparing ibu vs keto looks clinically meaningful. In the end, I don't think this study really adds anything to my knowledge.