What is the most effective Non-Steroidal Anti-Inflammatory Drug (NSAID) for acute lower back pain?

From the Guidelines

For acute lower back pain, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are the most effective options. When considering the treatment of acute lower back pain, it is essential to weigh the benefits and risks of different medications, including their potential impact on morbidity, mortality, and quality of life. According to the American College of Physicians and the American Pain Society guideline 1, NSAIDs have been shown to have moderate, primarily short-term benefits for patients with low back pain. The guideline recommends that clinicians assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy. Some key points to consider when prescribing NSAIDs for acute lower back pain include:

• Using the lowest effective doses for the shortest periods necessary to minimize adverse events
• Assessing cardiovascular and gastrointestinal risk factors before prescribing NSAIDs
• Considering strategies for minimizing adverse events in higher-risk patients, such as co-administration with a proton-pump inhibitor
• Being aware of the association between exposure to cyclooxygenase-2–selective or most nonselective NSAIDs and increased risk for myocardial infarction, as noted in the guideline 1. Given the potential benefits and risks, ibuprofen or naproxen are reasonable first-line NSAID options for acute lower back pain, with the understanding that their use should be judicious and monitored for potential adverse effects, as recommended by the guideline 1.

From the Research

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for Acute Lower Back Pain

• The most effective NSAID for acute lower back pain is not clearly established, as different studies have reported varying results 2, 3, 4, 5, 6
• A study comparing ibuprofen, ketorolac, and diclofenac for acute, nonradicular low back pain found no significant differences in primary outcomes, but ketorolac may result in better pain relief and less stomach irritation than ibuprofen 3
• Another study found that nimesulide, a COX-2-selective anti-inflammatory drug, was more effective than ibuprofen in improving functional status and had fewer gastrointestinal side effects 5
• The choice of NSAID should be based on patient risk factors for NSAID-related adverse effects, such as gastrointestinal, renovascular, or cardiovascular effects 2, 4
• Combination therapy with a nonsteroidal anti-inflammatory agent and a muscle relaxant may be beneficial for patients with muscle spasm associated with acute low back strain 6

Comparison of NSAIDs

• Ibuprofen, ketorolac, and diclofenac have similar analgesic effects, but may differ in terms of side effects and efficacy 3
• Nimesulide, a COX-2-selective anti-inflammatory drug, may have a lower incidence of gastrointestinal side effects compared to ibuprofen 5
• Naproxen, a nonsteroidal anti-inflammatory agent, may be effective in combination with a muscle relaxant, such as cyclobenzaprine, for relief of muscle spasm associated with acute low back strain 6

Patient-Specific Factors

• Patient risk factors, such as gastrointestinal, renovascular, or cardiovascular effects, should be considered when choosing an NSAID 2, 4
• The presence of muscle spasm associated with acute low back strain may benefit from combination therapy with a nonsteroidal anti-inflammatory agent and a muscle relaxant 6