Gabapentinoids, oral corticosteroids and benzodiazepines should not be offered to patients with sciatica, according to a draft update from the National Institute for Health and Care Excellence (NICE).
The guideline, originally published in 2016, covers the assessment and management of low back pain and sciatica and the 2020 update, which is currently out for consultation, advises that gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines should not be offered to patients for the management of sciatica. It also says opioids should not be offered for the management of chronic sciatica.
It advises that any patient taking opioids, gabapentinoids or benzodiazepines for sciatica should be made aware of problems associated with withdrawal.
Finally, it says that prescribers should be aware that there was limited evidence of benefit for the use of non-steroidal anti-inflammatory drugs in sciatica.
The NICE committee said that the updates were based on evidence that indicated that gabapentinoids and oral corticosteroids did not improve sciatica symptoms and both increased the risk of adverse events in the long term. The recommendations also took into account the reclassification of gabapentinoids as a Schedule 3 controlled drug in 2019.
Benzodiazepines were not associated with a risk of adverse events, but there was evidence of a poorer response to placebo in terms of pain reduction, the committee said.
They also said that there was no evidence on the use of other antiepileptics or opioids for sciatica.
Emma Davies, advanced pharmacy practitioner in pain management at Cwm Taf Morgannwg University Health Board, said the recommendations were “sound” on the basis of existing evidence and how NICE makes its assessments.
“I think they are careful in weighing up the limited potential benefits and the very obvious risks of all the medicine groups involved,” she explained.
“My concern, as always, is that NICE do not have the power or influence to actually mandate service changes. So, while I agree that people should get self-management support, psychologically informed practice etc., it is hard to achieve this in practice and too often it is only available when all medical and surgical possibilities are exhausted.
“This needs to change and should include a lot more high-profile public messaging and education … pharmacy teams in community need to upskill in this area and be better able to have conversations about back pain and sciatica that do not encourage or result in the sale of medication.”
The final updated guideline is expected to be published on 22 September 2020.