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Cochrane Database of Systematic Reviews

Agentes antiinflamatorios no esteroideos para el dolor lumbar crónico

Información

DOI:
https://doi.org/10.1002/14651858.CD012087Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 10 febrero 2016see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:

  1. Grupo Cochrane de Espalda y cuello

Copyright:
  1. Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Contraer

Autores

  • Wendy TM Enthoven

    Correspondencia a: Department of General Practice, Erasmus Medical Center, Rotterdam, Netherlands

    [email protected]

  • Pepijn DDM Roelofs

    Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, Netherlands

  • Richard A Deyo

    Department of Family Medicine, Dept. of Medicine, Dept. of Public Health & Preventive Medicine, Oregon Health and Science University, Portland, USA

  • Maurits W van Tulder

    Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, Netherlands

  • Bart W Koes

    Department of General Practice, Erasmus Medical Center, Rotterdam, Netherlands

Contributions of authors

BW Koes, PDDM Roelofs and WTM Enthoven screened titles and abstracts. WTM Enthoven and PDDM Roelofs performed methodological quality assessments, data extraction and data analyses. WTM Enthoven wrote the initial draft of the manuscript and all review authors critically reviewed the manuscript.

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • Dutch Arthritis Foundation, Netherlands.

    This Cochrane review is partly funded by a Dutch Arthritis Foundation programme grant.

Declarations of interest

Wendy TM Enthoven has no known conflicts of interest.

Pepijn DDM Roelofs has no known conflicts of interest.

Richard A Deyo has no known conflicts of interest.

Maurits W van Tulder has no known conflicts of interest.

Bart W Koes has no known conflicts of interest.

Acknowledgements

We thank Shireen Harbin and Rachel Couban, Trials Search Co‐ordinators of the Cochrane Back Review Group, who updated the literature searches. We also thank Rob Scholten for his contributions to the original Cochrane review (Roelofs 2008).

Version history

Published

Title

Stage

Authors

Version

2016 Feb 10

Non‐steroidal anti‐inflammatory drugs for chronic low back pain

Review

Wendy TM Enthoven, Pepijn DDM Roelofs, Richard A Deyo, Maurits W van Tulder, Bart W Koes

https://doi.org/10.1002/14651858.CD012087

Differences between protocol and review

We excluded NSAIDs which are no longer available on the market, such as rofecoxib, from this Cochrane review. We had not previously stated this in the Cochrane protocol.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Humans;

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

study flow diagram.
Figuras y tablas -
Figure 1

study flow diagram.

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'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included trial.
Figuras y tablas -
Figure 2

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included trial.

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'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included trials.
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Figure 3

'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included trials.

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Funnel plot of comparison: 1 NSAIDs versus placebo, outcome: 1.1 Change in pain intensity from baseline on 100 mm VAS. Follow‐up ≤ 12 weeks.
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Figure 4

Funnel plot of comparison: 1 NSAIDs versus placebo, outcome: 1.1 Change in pain intensity from baseline on 100 mm VAS. Follow‐up ≤ 12 weeks.

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Funnel plot of comparison: 1 NSAIDs versus placebo, outcome: 1.2 Change in disability from baseline.
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Figure 5

Funnel plot of comparison: 1 NSAIDs versus placebo, outcome: 1.2 Change in disability from baseline.

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Funnel plot of comparison: 1 NSAIDs versus placebo, outcome: 1.3 Proportion of patients experiencing adverse events. Follow‐up ≤ 16 weeks.
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Figure 6

Funnel plot of comparison: 1 NSAIDs versus placebo, outcome: 1.3 Proportion of patients experiencing adverse events. Follow‐up ≤ 16 weeks.

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Comparison 1 NSAIDs versus placebo, Outcome 1 Change in pain intensity from baseline on 100 mm VAS. Follow‐up ≤ 16 weeks..
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Analysis 1.1

Comparison 1 NSAIDs versus placebo, Outcome 1 Change in pain intensity from baseline on 100 mm VAS. Follow‐up ≤ 16 weeks..

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Comparison 1 NSAIDs versus placebo, Outcome 2 Change in disability from baseline.
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Analysis 1.2

Comparison 1 NSAIDs versus placebo, Outcome 2 Change in disability from baseline.

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Comparison 1 NSAIDs versus placebo, Outcome 3 Proportion of patients experiencing adverse events. Follow‐up ≤ 16 weeks..
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Analysis 1.3

Comparison 1 NSAIDs versus placebo, Outcome 3 Proportion of patients experiencing adverse events. Follow‐up ≤ 16 weeks..

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Comparison 1 NSAIDs versus placebo, Outcome 4 Sensitivity analysis: change in pain intensity from baseline on 100 mm VAS. Follow‐up ≤ 16 weeks..
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Analysis 1.4

Comparison 1 NSAIDs versus placebo, Outcome 4 Sensitivity analysis: change in pain intensity from baseline on 100 mm VAS. Follow‐up ≤ 16 weeks..

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Comparison 1 NSAIDs versus placebo, Outcome 5 Sensitivity analysis: change in disability from baseline.
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Analysis 1.5

Comparison 1 NSAIDs versus placebo, Outcome 5 Sensitivity analysis: change in disability from baseline.

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Comparison 1 NSAIDs versus placebo, Outcome 6 Sensitivity analysis: proportion of patients experiencing adverse events. Follow‐up ≤ 16 weeks..
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Analysis 1.6

Comparison 1 NSAIDs versus placebo, Outcome 6 Sensitivity analysis: proportion of patients experiencing adverse events. Follow‐up ≤ 16 weeks..

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Comparison 2 NSAIDs versus other drug treatment, Outcome 1 Proportion of patients experiencing global improvement. Follow‐up ≤ 6 weeks..
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Analysis 2.1

Comparison 2 NSAIDs versus other drug treatment, Outcome 1 Proportion of patients experiencing global improvement. Follow‐up ≤ 6 weeks..

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Comparison 2 NSAIDs versus other drug treatment, Outcome 2 Proportion of patients experiencing adverse events. Follow‐up ≤ 6 weeks..
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Analysis 2.2

Comparison 2 NSAIDs versus other drug treatment, Outcome 2 Proportion of patients experiencing adverse events. Follow‐up ≤ 6 weeks..

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Summary of findings for the main comparison. NSAIDs for people with chronic low back pain

NSAIDs for people with chronic low back pain compared to placebo

Participant or population: people with chronic low back pain
Settings: General practice and outpatient clinic
Intervention: NSAIDs

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(trials)

Quality of the evidence
(GRADE)

Assumed risk

Corresponding risk

Control

NSAIDs

Change in pain intensity from baseline
100 mm VAS
Follow‐up: 9 to 112 days

Not estimable

The mean change in pain intensity from baseline in the intervention groups was
6.97 lower
(10.74 to 3.19 lower)

‐

1354
(6 trials)

⊕⊕⊝⊝
low1,2,3

Change in disability from baseline
RDQ 0 to 24
Follow‐up: 4 to 16 weeks

Not estimable

The mean change in disability from baseline in the intervention groups was
0.85 lower
(1.30 to 0.40 lower)

‐

1161
(4 trials)

⊕⊕⊝⊝
low3,4,5

Proportion of participants experiencing adverse events
Follow‐up: 9 to 112 days

Study population

RR 1.04
(0.92 to 1.17)

1354
(6 trials)

⊕⊕⊝⊝
low1,2,3

410 per 1000

427 per 1000
(378 to 480)

Moderate

477 per 1000

496 per 1000
(439 to 558)

Sensitivity analysis: change in pain intensity from baseline
100 mm VAS
Follow‐up: 2 to 16 weeks

Not estimable

The mean sensitivity analysis change in pain intensity from baseline. in the intervention groups was
5.03 lower
(10.37 lower to 0.32 higher)

‐

728
(3 trials)

⊕⊕⊕⊝
moderate6

Sensitivity analysis: change in disability from baseline
RDQ 0 to 24
Follow‐up: 6 to 16 weeks

Not estimable

The mean sensitivity analysis change in disability from baseline in the intervention groups was
0.41 lower
(1.04 lower to 0.23 higher)

‐

654
(2 trials)

⊕⊕⊕⊝
moderate7

Sensitivity analysis: proportion of participants experiencing adverse events. Follow‐up ≤ 16 weeks
Follow‐up: 2 to 16 weeks

Study population

RR 0.93
(0.81 to 1.07)

728
(3 trials)

⊕⊕⊕⊝
moderate6

536 per 1000

498 per 1000
(434 to 573)

Moderate

522 per 1000

485 per 1000
(423 to 559)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio; RDQ: Roland Morris Disability Questionnaire. VAS: Visual Analogue Scale

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1Allocation concealment was uncertain in most included trials, and randomization was uncertain in half of the included trials, therefore selection bias is likely. Five out of six trials had high drop‐out rates, so attrition bias is likely, one level downgrade.
2Two out of six trials allowed co‐interventions. Two trials included a 'flare design', one level downgrade.
3See funnel plot: we could not detect publication bias, no downgrade.
4Allocation concealment was uncertain in most included trials. All four trials had high drop‐out rates, so attrition bias is highly likely, one level downgrade.
5One included trial allowed co‐interventions. One trial included a 'flare design', one level downgrade.
6Allocation concealment and randomization were uncertain in all included trials, therefore selection bias is likely. Two out of three included trials had high drop‐out rates, so attrition bias is likely, one level downgrade.
7Allocation concealment and randomization was uncertain in both trials, therefore selection bias is likely. Both trials had high drop‐out rates, so attrition bias is likely, one level downgrade.

Figuras y tablas -
Summary of findings for the main comparison. NSAIDs for people with chronic low back pain
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Comparison 1. NSAIDs versus placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Change in pain intensity from baseline on 100 mm VAS. Follow‐up ≤ 16 weeks. Show forest plot

6

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 All NSAIDs

6

1354

Mean Difference (IV, Random, 95% CI)

‐6.97 [‐10.74, ‐3.19]

1.2 Non‐selective NSAIDs

4

847

Mean Difference (IV, Random, 95% CI)

‐5.96 [‐10.96, ‐0.96]

1.3 Selective NSAIDs

2

507

Mean Difference (IV, Random, 95% CI)

‐9.11 [‐13.56, ‐4.66]

2 Change in disability from baseline Show forest plot

4

1161

Mean Difference (IV, Fixed, 95% CI)

‐0.85 [‐1.30, ‐0.40]

3 Proportion of patients experiencing adverse events. Follow‐up ≤ 16 weeks. Show forest plot

6

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1 All NSAIDs

6

1354

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.92, 1.17]

3.2 Non‐selective NSAIDs

4

847

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.82, 1.08]

3.3 Selective NSAIDs

2

507

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [1.00, 1.56]

4 Sensitivity analysis: change in pain intensity from baseline on 100 mm VAS. Follow‐up ≤ 16 weeks. Show forest plot

3

728

Mean Difference (IV, Random, 95% CI)

‐5.03 [‐10.37, 0.32]

5 Sensitivity analysis: change in disability from baseline Show forest plot

2

654

Mean Difference (IV, Fixed, 95% CI)

‐0.41 [‐1.04, 0.23]

6 Sensitivity analysis: proportion of patients experiencing adverse events. Follow‐up ≤ 16 weeks. Show forest plot

3

728

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.81, 1.07]
Figuras y tablas -
Comparison 1. NSAIDs versus placebo
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Comparison 2. NSAIDs versus other drug treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Proportion of patients experiencing global improvement. Follow‐up ≤ 6 weeks. Show forest plot

2

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

2 Proportion of patients experiencing adverse events. Follow‐up ≤ 6 weeks. Show forest plot

3

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 2. NSAIDs versus other drug treatment
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