What is the best nonsteroidal anti-inflammatory drug (NSAID) for back pain?

Best NSAID for Back Pain

For most patients with back pain, nonselective NSAIDs are recommended as first-line medication options, with no specific NSAID demonstrating superior efficacy over others. 1

NSAID Selection Algorithm

First-Line Options:

• Nonselective NSAIDs (ibuprofen, naproxen, diclofenac)
  • More effective than acetaminophen for pain relief 1
  • Demonstrated superior efficacy compared to placebo for both acute and chronic low back pain 1

Patient-Specific Considerations:

1. For acute low back pain:

   • Oral ibuprofen (400-600mg every 6-8 hours) appears more effective than topical diclofenac 2
   • Ketorolac may provide better pain relief with less stomach irritation than ibuprofen (80% vs 62% reporting mild or no pain after 5 days) 3

2. For older patients:

   • Use caution with all NSAIDs due to increased risk of adverse effects
   • Consider lower doses and shorter duration of therapy 1
   • Monitor for gastrointestinal, cardiovascular, and renal adverse effects

3. For patients with GI risk factors:

   • Consider co-administration with a proton-pump inhibitor 1
   • Celecoxib may have fewer significant gastrointestinal adverse events 1

4. For patients with cardiovascular risk factors:

   • Assess cardiovascular risk before prescribing any NSAID
   • Use the lowest effective dose for the shortest duration 1
   • Be aware of increased myocardial infarction risk with most NSAIDs 1

Evidence Summary

Efficacy:

• NSAIDs are superior to placebo for global improvement in acute low back pain (RR 1.24) 1
• For chronic low back pain, NSAIDs show a small but significant effect compared to placebo 4
• No clear evidence that any specific NSAID is superior to others for pain relief 1
• Recent research suggests ketorolac may have advantages over ibuprofen for acute low back pain 3

Combination Therapy:

• Adding muscle relaxants to NSAIDs may not provide additional benefit for acute low back pain 5
• However, some evidence suggests combining indomethacin with methocarbamol improves outcomes 6

Formulation Considerations:

• Oral NSAIDs appear more effective than topical formulations for low back pain 2
• Topical NSAIDs don't demonstrate additive benefit when combined with oral NSAIDs 2

Important Cautions

• Limit duration: Use the lowest effective dose for the shortest period necessary 1
• GI risks: Monitor for gastrointestinal bleeding, especially in older adults 1
• Cardiovascular risks: All NSAIDs (except aspirin) may increase risk of myocardial infarction 1
• Renal risks: Monitor renal function, especially in patients with existing kidney disease
• Drug interactions: Be aware of potential interactions with antihypertensives, anticoagulants, and other medications

Monitoring Recommendations

• Assess pain and functional improvement within 1-2 weeks
• Monitor for adverse effects, particularly in high-risk patients
• Consider alternative or adjunctive treatments if inadequate response
• For chronic use, periodically reassess need for continued NSAID therapy

Remember that NSAIDs should be used in conjunction with non-pharmacological approaches such as heat therapy, appropriate physical activity, and education about back care 1, 7.