Marek Hakl, M.D., Ph.D.
Vice President of Czech Neuromodulation Society
Dept of Anaesthesiology and Intensive Care
St Anne's University Hospital Brno
Management of acute low back pain
1) In your practice, what is the first line pharmacological treatment for acute low back pain?
There are two main approaches to low back pain: pharmacological and non-pharmacological. Both approaches are very important for a successful treatment. With respect to pharmacological treatment, NSAIDs and muscle relaxants are the first line drugs. In some patient with severe pain we use high dose (3 g/day) paracetamol, and/or tramadol.
2) In your opinion, what are the most important features for an oral NSAID in the treatment of acute low back pain?
From a clinical point of view, the most important features are the rapid onset of the analgesic effect and the low incidence of adverse events.
For some patients, the cost of a drug is also important, especially in case of expensive pain killers.
With regard to the formulation, some patients prefer non-tablet formulations.
3) Do you use topical and systemic combination of NSAIDs in patients with acute low back pain?
Yes, I often combine systemic and topical formulations of NSAIDs in this kind of patients. The main advantage of this co-administration is the possibility of obtaining high concentrations of the active substance at the inflammatory site by decreasing at the same time the systemic level: therefore, this strategy diminishes the risk of systemic side effects.
4) What is the main advantage of nimesulide in patients with acute low back pain?
The majority of patients prefer nimesulide for its effective analgesic action, in terms of fast onset and duration. With regard to the oral administration, my patients usually prefer the not-tablet formulation.
5) In your experience how the rapid onset of the analgesic effect is important for a NSAID
indicated for the treatment of acute low back pain?
From my point of view the rapid onset of the analgesic effect is one of the most important features of an analgesic drug in patients with low back pain. Patients want to obtain relief from pain immediately. For example, among preferential inhibitors of COX-2 meloxicam has a good, but very slow analgesic effect; therefore I do not use this drug for the treatment of this condition.
6) Is there any significant difference in terms of benefit-risk among different NSAIDs?
Yes, I prefer to use NSAIDs that preferentially inhibit COX-2, because they are associated with a reduced incidence of dyspepsia, and of other gastro-intestinal events.
Management of traumatic injuries
1) In your practice what is the first line topical treatment for traumatic injuries?
NSAIDs play a fundamental role. The choice of the given NSAID largely depends on the single patient's preference. In most cases, I don´t recommend drugs which are associated with a risk of photosensitization. In addition, the cost of a topic formulation should be taken into account.
2) In your opinion, what are the most important features for a topical NSAID indicated for the treatment of traumatic injuries?
I'd like to indicate three main aspects: the low risk of local reactions, the easiness of application, and the deep penetration across the skin. Sometimes the smell of a cream or of a gel can be important in driving the patient's choice.
3) What is the main advantage of topical nimesulide in patients with traumatic injuries?
The main advantage of topical nimesulide is its very good analgesic effect, which is related to an excellent skin penetration. Another very important characteristic is the absence of local irritation after application.
4) In your experience how the rapid onset of the analgesic effect is important for a NSAID indicated for the treatment of traumatic injuries?
It is extremely important. Patients with acute pain want to obtain an immediate pain relief. This aspect is particularly relevant when the treatment is based only on the use of topical formulations.
However, the rapid onset of the analgesic action is crucial also in case of treatment with systemic NSAIDs, either alone or in combination.