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Research ArticlePractice

Cyclobenzaprine for acute back pain

Emélie Braschi, Scott Garrison and G. Michael Allan
Canadian Family Physician December 2015, 61 (12) 1074;
Emélie Braschi
is a family medicine resident at McGill University in Montreal, Que. is Associate Professor and Dr Allan is Professor and Director of Evidence-Based Medicine in the Department of Family Medicine at the University of Alberta in Edmonton.
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Scott Garrison
is a family medicine resident at McGill University in Montreal, Que. is Associate Professor and Dr Allan is Professor and Director of Evidence-Based Medicine in the Department of Family Medicine at the University of Alberta in Edmonton.
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G. Michael Allan
is a family medicine resident at McGill University in Montreal, Que. is Associate Professor and Dr Allan is Professor and Director of Evidence-Based Medicine in the Department of Family Medicine at the University of Alberta in Edmonton.
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Clinical question

How effective is cyclobenzaprine for acute back pain?

Bottom line

Cyclobenzaprine reduces pain and leads to global improvement compared with placebo for 1 in every 3 to 9 patients in the first week. Cyclobenzaprine generally adds little to naproxen. Taken 3 times daily, 5 mg is as effective as 10 mg, with less somnolence.

Evidence

  • In 3 systematic reviews (9 to 46 RCTs, 820 to 5401 patients) of non-benzodiazepine muscle relaxants versus placebo, differences were statistically significant1–3:

    • –Pain scores were about 12 points lower on a 100-point visual analogue scale at 10 days.1

    • –There was undefined pain reduction (number needed to treat [NNT] of 4 to 7) at 2 to 7 days; an undefined target for global efficacy (NNT = 4) was achieved at 2 to 4 days.2

  • Cyclobenzaprine versus placebo:

    • –One systematic review (14 RCTs, 3023 patients) showed global improvement (NNT = 3) at about 10 days.4

    • –We pooled data from 2 publications with 2 RCTs each.

      • —Pain relief (1389 patients) was achieved at 7 days in 50% of those taking 5 mg of cyclobenzaprine 3 times daily versus 38% taking placebo (NNT = 9; P < .001).5 No difference was noted in 5 mg versus 10 mg or 2.5 mg versus placebo.

      • —No difference was noted between 30 mg extended release once daily and 10 mg immediate release 3 times daily (504 patients).6

  • An RCT of cyclobenzaprine plus ibuprofen (867 patients) showed no benefit to adding ibuprofen.7

  • An RCT of naproxen plus cyclobenzaprine (323 patients) showed no benefit to adding cyclobenzaprine at day 7, but only about 30% had frequent or continual back pain then.8

Context

  • Most trials were industry sponsored; had small samples, short durations, and poorly defined targets; and were unclear about whether cutoffs were clinically meaningful.4

  • No differences in efficacy were seen among the muscle relaxants, although cyclobenzaprine was more consistently evaluated.3 Cyclobenzaprine is equal or superior to diazepam.3 Other direct comparisons are lacking.

  • Adverse events include dose-related somnolence and dry mouth. Somnolence occurred in 10% of those taking placebo, 29% taking 5 mg 3 times daily, and 38% taking 10 mg 3 times daily.5

    • –Taken 3 times daily, 10 mg caused more somnolence than 5 mg (number needed to harm of 12).

    • –Rates of discontinuation owing to somnolence were 0.8% for placebo, 2.5% for 5 mg 3 times daily, and 5.2% for 10 mg 3 times daily.5

  • Guidelines recommend cyclobenzaprine for the treatment of acute low back pain.9

Implementation

About 50% to 90% of people will have back pain; about 90% of those cases will be nonspecific.9 X-ray scans are discouraged for acute nonspecific back pain.10 For acute back pain, acetaminophen is no better than placebo11; NSAIDs provide global improvement for 1 in every 11 patients compared with placebo.12 Cyclobenzaprine is structurally similar to tricyclic antidepressants and has similar adverse events. It should be avoided in the elderly13 and be given as 5 mg. While muscle relaxants have abuse potential,14 we did not find studies describing abuse of cyclobenzaprine.

Footnotes

  • The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

  • Copyright© the College of Family Physicians of Canada

References

  1. ↵
    1. Machado LA,
    2. Kamper SJ,
    3. Herbert RD,
    4. Maher CG,
    5. McAuley JH
    . Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology (Oxford) 2009;48(5):520–7.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Van Tulder MW,
    2. Touray T,
    3. Furlan AD,
    4. Solway S,
    5. Bouter LM
    . Muscle relaxants for nonspecific low back pain. Cochrane Database Syst Rev 2003;(2):CD004252.
  3. ↵
    1. Chou R,
    2. Peterson K,
    3. Helfand M
    . Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review. J Pain Symptom Manage 2004;28(2):140–75.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Browning R,
    2. Jackson JL,
    3. O’Malley PG
    . Cyclobenzaprine and back pain: a meta-analysis. Arch Intern Med 2001;161(13):1613–20.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Borenstein DG,
    2. Korn S
    . Efficacy of a low-dose regimen of cyclobenzaprine hydrochloride in acute skeletal muscle spasm: results of two placebo-controlled trials. Clin Ther 2003;25(4):1056–73.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Malanga GA,
    2. Ruoff GE,
    3. Weil AJ,
    4. Altman CA,
    5. Xie F,
    6. Borenstein DG
    . Cyclobenzaprine ER for muscle spasm associated with low back and neck pain: two randomized, double-blind, placebo-controlled studies of identical design. Curr Med Res Opin 2009;25(5):1179–96.
    OpenUrlPubMed
  7. ↵
    1. Childers MK,
    2. Borenstein D,
    3. Brown RL,
    4. Gershon S,
    5. Hale ME,
    6. Petri M,
    7. et al
    . Low-dose cyclobenzaprine versus combination therapy with ibuprofen for acute neck or back pain with muscle spasm: a randomized trial. Curr Med Res Opin 2005;21(9):1485–93.
    OpenUrlPubMed
  8. ↵
    1. Friedman BW,
    2. Dym AA,
    3. Davitt M,
    4. Holden L,
    5. Solorzano C,
    6. Esses D,
    7. et al
    . Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA 2015;314(15):1572–80.
    OpenUrlPubMed
  9. ↵
    Guideline for the evidence-informed primary care management of low back pain. 2nd ed. Edmonton, AB: Toward Optimized Practice; 2011.
  10. ↵
    1. Allan GM,
    2. Spooner GR,
    3. Ivers N
    . X-ray scans for nonspecific low back pain. A nonspecific pain? Can Fam Physician 2012;58:275.
    OpenUrlFREE Full Text
  11. ↵
    1. Williams CM,
    2. Maher CG,
    3. Latimer J,
    4. McLachlan AJ,
    5. Hancock MJ,
    6. Day RO,
    7. et al
    . Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet 2014;384(9954):1586–96.
    OpenUrlCrossRefPubMed
  12. ↵
    1. Roelofs PD,
    2. Deyo RA,
    3. Koes BW,
    4. Scholten RJ,
    5. van Tulder MW
    . Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev2008;(1):CD000396.
  13. ↵
    1. Spence MM,
    2. Shin PJ,
    3. Lee EA,
    4. Gibbs NE
    . Risk of injury associated with skeletal muscle relaxant use in older adults. Ann Pharmacother 2013;47(7–8):993–8.
    OpenUrlAbstract/FREE Full Text
  14. ↵
    1. Reeves RR,
    2. Ladner ME,
    3. Perry CL,
    4. Burke RS,
    5. Laizer JT
    . Abuse of medications that theoretically are without abuse potential. South Med J 2015;108(3):151–7.
    OpenUrlPubMed
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Canadian Family Physician: 61 (12)
Canadian Family Physician
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Cyclobenzaprine for acute back pain
Emélie Braschi, Scott Garrison, G. Michael Allan
Canadian Family Physician Dec 2015, 61 (12) 1074;

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Emélie Braschi, Scott Garrison, G. Michael Allan
Canadian Family Physician Dec 2015, 61 (12) 1074;
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