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NICE to reconsider advice that GPs should use gabapentinoids for sciatica



New research has suggested GPs should no longer prescribe gabapentinoids for sciatica, prompting NICE to review its current guidance.

The study published in the Canadian Medical Association Journal concluded that that gabapentinoids have no effect on pain or disability for sciatica or chronic lower back pain when compared with a placebo.

This comes as the Government are reviewing recommendations to make gabapentinoids class C drugs following a consultation earlier this year.

GP leaders said the benefits of gabapentinoids have been ‘enormously overstated’, leading to the current addiction issues faced by patients.

Researchers the University of Sydney reviewed nine studies that compared gabapentinoids to placebo in 859 patients with non-specific lower back pain, sciatica or neurogenic claudication of any duration.

The researchers found ‘moderate to high-quality evidence’ that gabapentinoids had no effect on pain or disability for sciatica and no short-term reduction in pain or disability compared with placebo for chronic lower back pain with or without radiating leg pain.

The research also found that ‘gabapentinoids have a higher risk for adverse events’.

The researchers wrote that the findings were ‘in line with recent United States and United Kingdom guidelines for low back pain’. 

But they added: ‘Regarding sciatica, the 2016 UK guideline recommends following neuropathic pain guidelines, which endorse the use of gabapentinoids. However, the recommendation of gabapentinoids for sciatica should be reviewed in light of emerging evidence.’

Currently, NICE recommends that GPs ‘offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia)’.

It then instructs them to ‘offer one of the remaining three drugs’ if the initial treatment is not effective.

A NICE spokesperson told Pulse that the guideline was reviewed in 2017 ‘and concluded there was insufficient evidence to prompt an update’.

But they added: ‘We will examine the new evidence to establish if it would require us to do an exceptional review of the guideline.’ 

The Government is currently reviewing recommendations to make gabapentinoids class C drugs, which could potentially see them kept in a safe with prescriptions written to specific legal requirements.

GP Committee prescribing and policy lead Dr Andrew Green said: ‘It is increasingly apparent to GPs working on the ground that the benefits of gabapentinoids were enormously overstated when they were introduced and we are now facing the problems of dependence on a massive scale.’

He continued: ‘GPs and our patients need services to which these patients can be referred rapidly if they show severe symptoms or have features on presentation that suggest they are at risk of chronicity.’

Charities have previously warned that discussions about reclassifying pregabalin and gabapentin as controlled drugs have created ‘fear and anxiety’ among the patients who use them responsibly.

The case against prescribing gabapentinoids

A Cochrane Review from June this year found that gabapentin ‘can provide good levels of pain relief to some people with postherpetic neuralgia and peripheral diabetic neuropathy’, but added that its effectiveness for other types of neuropathic pain ‘is very limited’.

Meanwhile, another study published in Addiction last year, that found that misuse of gabapentin was at a staggering ‘40-65% among individuals with prescriptions’.

GPs have previously been told by NHS England to prescribe Lyrica, and not pregabalin, for neuropathic pain – a decision which waslater overturned by a High Court decision.

However, Scottish-based health charity Pain Concern has said reclassifying gabapentinoids is creating ‘fear and anxiety’ among the patients who use them responsibly.