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NICE pushes through guidance limiting GP prescribing options for low back pain

NICE is going ahead with a drastic curb on drug options available to GPs for managing low back pain, advising GPs instead to focus on exercise and psychological therapies.

NICE has confirmed in its final clinical guidelines, ‘Low back pain and sciatica in over 16s: Assessment and management’ that GPs should not offer paracetamol alone and should ‘consider’ prescribing oral NSAIDs – such as ibuprofen or aspirin – for low back pain only at the ‘lowest effective dose and for the shortest possible time’.

The guidance, published in draft in March this year, stresses that GPs should ‘consider weak’ opioids (with or without paracetamol) for managing acute low back pain, only if an NSAID is ‘contraindicated, not tolerated or had been ineffective’.

It adds that GPs should not ‘routinely offer’ opioids for acute low back pain and not offer them at all for managing chronic back pain.

The final guidance also rejects therapies including acupuncture and a range of electrotherapies such as ultrasound and PENS (percutaneous electrical nerve simulation, as well as invasive treatments such as spinal injections – advising GPs to only consider referrals for the assessment for radiofrequency denervation when non-surgical treatment has not worked.

Imaging in a non-specialist setting should not be offered routinely, according to NICE. Instead, GPs are being urged to consider a range of options that do not involve medication or invasive procedures, including providing advice and information for patients to self manage their condition.

GPs are also asked to consider a group exercise programme – whether biomechanical, aerobic, mind-body or a combination. Manual therapies, such as massage, could be considered but only as apart of a treatment package, including exercise, with out without psychological therapy.

Like in the draft guidance, GPs are advised to consider risk stratification tools. But the final guidance also adds that for patients ‘likely to improve quickly and have a good outcome’ GPs should consider ‘simpler and less intensive support’, such as for example reassurance, advice to keep active and guidance to self-management.

For patients with a risk of poor outcome, GPs should consider more complex and intensive support such as exercise programmes with or without manual therapy or using a psychological approach, it adds.

Other changes from the draft guidance include adding ‘incorporating a cognitive behavioural approach’ to the recommendation on considering a combined physical and psychological programme.

And on pharmacological interventions NICE has downgraded its recommendation on NSAIDs, changing ‘offer’ to ‘consider’.

GP Dr Alastair Dickson, who provided evidence to NICE on behalf of the Primary Care Rheumatology Society, said he acknowledged the new guidance would be ‘a challenge’ to GPs and patients.

But he added that he was ‘very pleased’ by them as ‘the evidence is that drugs don’t work, especially paracetamol’.

‘They are dangerous and ineffective and it is good that NICE has backed away from this and followed the evidence,’ he said.

Dr Dickson also welcomed the guidance not to offer opioids for chronic low back pain because ‘we know that lots of people become addicted’.

RCGP chair Professor Helen Stokes-Lampard said: ‘We understand that some of the recommendations might be controversial. But the purpose of updating clinical guidelines is to take into account the latest research findings, and with a growing body of evidence suggesting that paracetamol has little more benefit for patients with lower back pain than a placebo, it makes sense that NICE reflects this.’

She also said RCGP agrees with ‘the important caveat in today’s guidance that [NSAIDS] should only be prescribed at the lowest possible dose for the shortest possible time’ because of the risk of side effects.

‘What is clear is that there is no one size fits all solution for patients with lower back pain, so the emphasis on combination therapies – be these physical, psychological or pharmacological – is very welcome and offers flexibility for both GPs and our patients,’ she added.

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