What is the appropriate management for a 44-year-old male patient presenting with myopia (nearsightedness) and lower back pain, currently requesting analgesia with ibuprofen (ibuprofen) and acetaminophen (paracetamol)?

From the Guidelines

I strongly advise against prescribing acetaminophen for the patient's low back pain due to its ineffectiveness, as suggested by the most recent and highest quality study 1. Instead, I recommend prescribing ibuprofen 400-600 mg every 6-8 hours with food as needed (not to exceed 3200 mg daily) for the patient's low back pain. The patient should be advised to take this medication for the shortest duration necessary, typically 3-7 days for acute pain. Ibuprofen reduces inflammation through prostaglandin inhibition, which can help alleviate the patient's low back pain. Since the patient already has a scheduled appointment with an optometrist for his nearsightedness (myopia), no additional intervention is needed for that complaint at this time. The patient should be instructed to return if back pain worsens, doesn't improve within 1-2 weeks, or if he experiences any concerning symptoms such as leg weakness, numbness, or bowel/bladder changes. It is essential to assess the patient's cardiovascular and gastrointestinal risk factors before prescribing NSAIDs, such as ibuprofen, and recommend the lowest effective doses for the shortest periods necessary, as suggested by previous studies 1. However, the most recent study 1 takes precedence in guiding the treatment decision, and its findings should be prioritized to ensure the best possible outcome for the patient. Key points to consider when prescribing ibuprofen include:

• Starting with a low dose and titrating as needed
• Monitoring for adverse effects, such as gastrointestinal issues or cardiovascular risks
• Advising the patient to take the medication with food to minimize gastrointestinal upset
• Scheduling follow-up appointments to assess the patient's response to treatment and adjust the plan as needed.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Carefully consider the potential benefits and risks of ibuprofen tablets and other treatment options before deciding to use ibuprofen tablets. Mild to moderate pain: 400 mg every 4 to 6 hours as necessary for relief of pain. The patient can be prescribed ibuprofen 400 mg every 4 to 6 hours as needed, and acetaminophen as requested for low back pain, while awaiting the optometrist appointment for nearsightedness evaluation 2.

From the Research

Patient's Condition

The patient is a 44-year-old male experiencing nearsightedness and low back pain. He reports being able to read perfectly but having difficulty seeing far signs and objects.

Medication Request

The patient has requested ibuprofen and acetaminophen for his low back pain.

Scheduled Appointment

The patient has a scheduled appointment with the optometrist regarding his nearsightedness.

Prescription

You will prescribe acetaminophen and ibuprofen in this visit.

Considerations for NSAID Use

• Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for rheumatic disorders, but their use is associated with gastrointestinal toxicity 3.
• Gastroprotective agents, such as proton pump inhibitors (PPIs), can reduce the risk of NSAID-induced gastrointestinal harm 4.
• The use of PPIs with NSAIDs is generally recommended in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids, or non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection 5, 6.
• However, recent evidence suggests that the gastrointestinal risks associated with NSAIDs can be potentiated when they are combined with PPIs 7.

Key Points to Consider

• The patient's low back pain may be managed with NSAIDs, but the risk of gastrointestinal toxicity should be considered.
• The use of PPIs with NSAIDs may be beneficial in reducing the risk of gastrointestinal harm, but the potential for increased cardiovascular risk should also be considered 5, 6.
• The patient's scheduled appointment with the optometrist will address his nearsightedness, but the prescription of acetaminophen and ibuprofen in this visit may help manage his low back pain.

Potential Interactions

• The use of NSAIDs, such as ibuprofen, may interact with other medications, including anticoagulants and antiplatelet agents, to increase the risk of gastrointestinal bleeding 5, 6.
• The patient's medical history and current medications should be carefully reviewed to minimize the risk of potential interactions.