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Sciatica (lumbar radiculopathy) - Management
How should I treat sciatic pain?

  • Provide adequate analgesia to manage the pain and to help the person keep active.
  • For first-line analgesia for mild pain, offer paracetamol.
  • If paracetamol is insufficient, offer a standard nonsteroidal anti-inflammatory drug (NSAID) or coxib.
    • When prescribing an NSAID or coxib:
      • Consider the risk of adverse effects, especially in older people, those at increased risk of gastrointestinal adverse effect, and those with asthma, chronic kidney disease, or heart conditions. See the section on People at increased risk in the CKS topic on NSAIDs - prescribing issues.
      • Prescribe a proton pump inhibitor (PPI) for people with increased risk of gastrointestinal (GI) bleeding, for example those older than 45 years of age.
      • Review NSAID/coxib treatment if the person develops dyspepsia. For information on management, see the section on Management with no alarm features, taking NSAID in the CKS topic on Dyspepsia - unidentified cause.
      • In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are recommended as first-line options.
  • For additional analgesia, consider the following options:
    • Paracetamol combined with an NSAID/coxib.
    • Adding a weak opioid such as codeine, dihydrocodeine, or tramadol.
      • Give due consideration to the risk of opioid dependence and adverse effects. When prescribing an opioid, consider the need for a laxative to counteract its constipating effects, as straining to defecate can aggravate the pain of sciatica.
  • For more potent analgesia, consider offering a short course of a strong opioid such as standard-release morphine, and co-prescribe a laxative and anti-emetic.
    • If the use of a strong opioid is becoming chronic, or if doses are escalating, refer to, or seek advice from, a pain clinic or other specialist service.
    • For morphine doses, and suggested laxatives and anti-emetics, see Prescriptions.
  • If the paraspinal muscles are in spasm, consider offering a short course (up to 5 days) of a benzodiazepine such as diazepam.
  • If sciatic pain does not respond to additional analgesics:
    • Consider offering amitriptyline (off-label use) or pregabalin (or gabapentin if there is a local decision to prefer gabapentin over pregabalin) for initial treatment.
      • Titrate the dosage according to response and tolerability.
      • For further information on contraindications, cautions, and managing adverse effects, see the CKS topic on Neuropathic pain - drug treatment.
    • Offer referral for physiotherapy.
    • Consider referral for assessment for epidural injection of corticosteroids.

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