Analysis of Non-steroidal Anti-inflammatory Drugs

Analysis of non-steroidal anti-inflammatory drugs efficiency on the pain reduction for people with sciatica in clinical practise and patient centred care.

Introduction

Low back pain (LBP) is a common disorder in the western world, affecting about 80 percent of the general western world population at some point in their life.⁸ According to Australian Bureau of statistics (ABS) 2014-2015 National Health Survey (NHS) 16% of the Australian population experience low back pain.¹⁰ Moreover, LBP have effects on the functional capacity of people in the work environment, creating a large economic and social burden on society.^{2, 8} Sciatica forms part of the LBP group and is in the heterogeneous subgroup.² Sciatica is a disorder that arise from pressure on the sciatic nerve root.^{3, ,9} Sciatica can be distinguish from LBP as radiating pain that follows a dermatomal pattern in the leg.^6  Sciatica is therefore a term to describe a specific symptom of LBP and is not a diagnosis itself.^2,5 The yearly estimated prevalence of sciatica is two percent up to fourteen percent.³ Out of every 1000 western world inhabitant 5-10 develop sciatica.¹²Sciatica also known by several synonyms in academic literature such as lumbosacral radicular syndrome, nerve root pain or nerve root compromise.³Causes of sciatica may or may not include trauma or injury to the spine, spinal canal narrowing and bone spurs.^1-2 Most sciatica cases are self-resolved between six and twelve weeks from the onset of symptoms.^9,12 However sciatica that does not resolve itself after a few weeks needs medical treatment.^6,9Treatment of sciatica is primarily aimed at pain reduction either by reducing pressure on the nerve root or by pain relieving drugs.⁶ The most common pain relieving drug prescribed for the pain management of sciatica is non-steroidal anti-inflammatory drugs. ^2,3 Non-steroidal anti-inflammatory drugs, reduce inflammation and swelling, relieve pain temporarily and lower a raised body temperature.

In the systematic (Cochrane) review “Non-steroidal anti-inflammatory drugs for sciatica” a number of people with chronic, subacute (pain for less than twelve weeks) and acute sciatica (pain of more than twelve weeks) aged sixteen years and older were examined. A total of ten randomised controlled trials (RCTs) were identified as eligible to be included in the systematic review, involving 1651 participants aged sixteen to seventy five years of age.² The aim for the review is to determine whether non-steroidal anti-inflammatory drugs have a pain reduction effect, whether it have an overall improvement and whether it have adverse side effects when compared to placebos, other non-steroidal anti-inflammatory drugs and other drugs in patients experiencing sciatica.² What was found is that non-steroidal anti-inflammatory drugs have no adverse effects in pain reduction for patients experiencing sciatica when compared to the placebo and other drugs. Non-steroidal anti-inflammatory drugs shown a better overall improvement when compared to other drugs and the placebo. However, this must be treated with caution as the trial quality is low. Non-steroidal anti-inflammatory drugs also shown a higher risk of side effects when compared to the placebo.²

This summative article will analyse the implications of these findings for clinical practice and patient-centred care, it will also interpret the findings of the systematic (Cochrane) review and discuss a range of clinical opinions and recommendations for medical students and registered health care professionals.

Discussion

Based on the systematic review and previous studies it was found that there was a limited benefit from non-steroidal anti-inflammatory drugs.² At the moment, there are a several treatment plans, apart from prescribing non-steroidal anti-inflammatory drugs on a chronic basis to reduce pain in patients suffering from sciatica.^6,15 Health professionals should consider these other treatment interventions to non-steroidal anti-inflammatory drugs as long term usage of non-steroidal anti-inflammatory drugs cause adverse risk to a patient.^1,2,3,19 Potential adverse risks may occur in the gastrointestinal (GI), renal, cardiovascular (CV), cerebrovascular, and central nervous system (CNS).^2,19Alternative  professional interventions include manipulative therapy, like chiropractic or osteopathy exercise therapy, physiotherapy, epidural injections, and surgery as a last resort.^9,15 Exercise therapy as a single treatment intervention compared to bed rest had little or no improvement at all for patients with sciatica. However prolonged bed rest have harmful effects for the patient.^6,9,18 It may therefore be reasonable for a health professional to prescribe exercise therapy along with other treatment interventions to prevent breaching the ethical obligation – non maleficence.⁹ Non maleficence may be defined as doing no harm to the patient involved or the society involved.¹³ Combining physiotherapy methods such as lumbar traction with other interventions seems to produce positive results in nerve root compression symptoms. Traction as a standalone intervention to date is not recommended as the most studies applied lumbar traction along with other interventions.⁸ Research into epidural injections, through a meta-analysis found that the injections had some improvements in pain reduction and disability scores in patients with acute sciatic.^6,7 The same research reported that exercise therapy is no better than inactive therapy, such as bedrest. Although surgery do not improve life quality and reduce the severity of sciatica symptoms evidence suggest that surgery is the best intervention to relieve pain fast in patients suffering sciatica.^6,16 Surgery will relieve sciatica pain nine out of ten times. However, there is a change of one in twenty that the pain will return at a later stage. Surgery, is usually reserved when the compressed nerve causes a significant weakness like loss of bladder control or bowl control or when the pain progressively worsens or does not improve with other non-invasive therapies.¹⁷ Further studies conclude that there is no significant difference in the clinical outcome between conservative treatments (physiotherapy and pharmaceutical interventions) and the invasive treatments like surgery after two years in patients with sciatica.The literature is therefore not consistant regarding the best treatment intervention, the choice of treatment can be considered preference sensitive.¹⁴ The Dutch multidisciplinary sciatica guideline recommend that share decision making is implemented in consultations. In share decision making both the, health professional and the patient makes a decision together, weighting the best available evidence of different treatment options against each other.^14,20 Patients are encouraged to consider between conservative treatment over a prolonged period and invasive treatments weighing the benefits and harm of each to select the best treatment for them.¹⁴

When making decisions about the course of clinical practice in a patient consultation, it is important to remember patients have a right to make a well-informed decision about their treatment option.²² It would be appropriate to disclose the findings of this systematic review to patients considering the use of non-steroidal anti-inflammatory drugs so that a patient can make an informed decision regarding treatment options. It is essential that patients seeking treatment for sciatica understand the true extent of the efficacy of non-steroidal anti-inflammatory drugs: that it only has minimal (if any) pain reduction effects when compared to a placebo or other drugs.²