Medication should be used in conjunction with physical therapy, exercise regimens, and the treatment of the underlying degenerative disease process and medical illness.
Growing numbers of elderly persons have spinal pain. Although medications are crucial for pain management, geriatric patients cannot utilize them too much due to decreased liver and kidney function, comorbid diseases, and polypharmacy (the simultaneous use of multiple drugs to treat medical conditions).
A recent review study has shown that acetaminophen is safe in older adults, but nonsteroidal anti-inflammatory drugs (ibuprofen) may be more beneficial for spinal pain. Nonsteroidal anti-inflammatories should be used in lower dosage courses for a short period of time with gastrointestinal caution, whereas corticosteroids have the least evidence for treating nonspecific back pain.
Additionally, older adults may utilize the anti-nerve-pain drugs gabapentin and pregabalin with prudence about dosage and kidney function. With consideration for potential drowsiness and dizziness, newer antidepressants (duloxetine) may assist with back pain more so than older ones (nortriptyline). With consideration for kidney and liver function, several muscle relaxants (such as baclofen and tizanidine) may be taken by older people. Opioids have little use in treating typical back pain, although they may be used cautiously in circumstances when other treatments are ineffective.
“Most older people experience neck or low back pain at some point, bothersome enough to see their doctor. Our findings provide a helpful medication guide for physicians to use for spine pain in an older population that can have a complex medical history,” explained corresponding author Michael D. Perloff, MD, Ph.D. He is an assistant professor of neurology at Boston University School of Medicine (BUSM) and a neurologist at Boston Medical Center.
The researchers performed a literature review to assess the evidence-basis for medications used for spine-related pain in older adults, with a focus on drug metabolism and adverse drug reactions. They then provided their recommendations based on safe and effective dosing.
Among their findings:
- Pain medicines gabapentin and pregabalin may cause dizziness or difficulty walking, but may have some benefits for neck and back nerve pain (such as sciatica) in older adults. They should be used in lower doses with smaller dose adjustments.
- Some muscle relaxants (carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, and orphenadrine) are avoided in older adults due to the risk for sedation and falls. Others (tizanidine, baclofen, dantrolene) may be helpful for neck and back pain, with the most evidence for tizanidine and baclofen. These should be used in reduced doses, avoiding tizanidine with liver disease and reducing baclofen dosing with kidney disease.
- Older antidepressants are typically avoided in older adults due to their side effects, but nortriptyline and desipramine may be better tolerated for neck and back nerve pain at lower doses. Overall, newer antidepressants (namely duloxetine) have a better safety profile and good efficacy for spine-related nerve pain.
- Tramadol may be tolerated in older adults, but has the risk for sedation, upset stomach, and constipation. It may be used in lower doses after alternative medications have failed and works well with co-administered acetaminophen. Opioids are avoided due to their side effects and mortality risk, but low-dose opioid therapy may be helpful for severe refractory pain with close monitoring of patients clinically.
According to the researchers, complementary medicine, physical therapy, injections and surgery all have a place to help older persons with spine-related pain. “Medications used at the correct dose, for the correct diagnosis, adjusting for preexisting medical problems can result in better use of treatments for spine pain,” added first author Jonathan Fu, a 2022 MD graduate from BUSM.
Reference: “Pharmacotherapy for Spine-Related Pain in Older Adults” by Jonathan L. Fu and Michael D. Perloff, 27 June 2022, Drugs & Aging.