In reply
We thank Dr Geller for his letter regarding our recent article.1 In his letter, Dr Geller suggests that clinicians appropriately reject evidence-based guidelines for LBP because (1) the use of paracetamol poses an unacceptably high risk of adverse events compared with NSAIDs and (2) opioids have some benefit in disease progression.
In LBP management, NSAIDs are effective, but no more than paracetamol, which has fewer adverse effects.2 Schilling et al3(p19) highlight that paracetamol “is generally considered safe, but high doses can be toxic.” Their report identifies that paracetamol-related toxic effects occur with ingestion of excessive doses, knowingly or unknowingly, or when contraindication or precautions are present. While other reports of paracetamol toxicity exist,4 these cases reveal multiple causative factors and fail to implicate paracetamol as causing significant toxic effects at recommended doses.5 Mortensen and Cullen5(p1482) state “unfortunately, the extensive literature on the subject of chronic acetaminophen toxicity includes opinions drawn from unsubstantiated case reports.”