NICE updates sciatica treatment guidance

GPs should not offer gabapentinoids or other anticonvulsants, oral corticosteroids or benzodiazepines to patients with sciatica as there is no overall evidence these drugs are beneficial and they can cause harm, according to the updated NICE guideline on low back pain and sciatica in the over 16s. 

Lack of evidence

The evidence reviewed by NICE showed that gabapentinoids did not improve sciatica symptoms, and oral corticosteroids did not improve pain or function, although they may improve quality of life. Both types of drugs increased the risk of adverse events in the long term. While there was no evidence that benzodiazepines increased the risk of adverse events, their efficacy in terms of pain reduction appeared to be poorer than that of placebo.

The guideline committee agreed that although the evidence about the lack of effectiveness of these drug classes was limited, the harms would outweigh the benefits for most people. 

The committee found no evidence on the use of opioids, or anticonvulsants other than gabapentin or pregabalin, for sciatica. Given the potential harms of long-term use, the guideline recommends against prescribing opioids for chronic sciatica. Research is needed to establish whether short-term opioid use might be beneficial for acute sciatica, it says.

There was also no evidence on the use of antidepressants, but these drugs are commonly prescribed for sciatica, and clinical experience suggests they may be of benefit in some people. The committee considered the potential for harm to be less than the harms of prolonged use of opioids.

NICE acknowledges that some people may have already been taking opioids, gabapentinoids and benzodiazepines for long periods to treat sciatica. In these cases, the prescriber should explain the risks of continuing the medicines as well as the problems associated with withdrawal. 

NSAIDs

NICE concluded there was insufficient evidence to make a recommendation for or against the use of NSAIDs for sciatica. If prescribing NSAIDs for the condition, it advises prescribers to:

• take into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age
• think about appropriate clinical assessment, ongoing monitoring of risk factors, and the use of gastroprotective treatment
• use the lowest effective dose for the shortest possible period of time. 

No evidence was identified for paracetamol, nefopam or muscle relaxants other than benzodiazepines for the management of sciatica, but none of these are widely prescribed for sciatica.