What is the recommended anti-inflammatory medication for recurring back pain?

Recommended Anti-inflammatory Medication for Recurring Back Pain

NSAIDs are the first-line anti-inflammatory medication for recurring back pain due to their proven effectiveness for pain relief. 1

First-Line Medication Options

• NSAIDs (such as naproxen or ibuprofen) are recommended as initial treatment for recurring back pain with moderate short-term benefits for pain relief 1
• Acetaminophen is an alternative first-line option with a more favorable safety profile but slightly weaker analgesic effect than NSAIDs (approximately 10 points less effective on a 100-point pain scale) 1
• For acute exacerbations of back pain, skeletal muscle relaxants can be added for short-term use, showing good evidence of effectiveness 1, 2

NSAID Selection and Safety Considerations

• Both traditional NSAIDs and selective COX-2 inhibitors provide similar pain relief benefits 3
• NSAID risks include:
  • Gastrointestinal complications (ulcers, bleeding) that increase with age 4, 5
  • Cardiovascular risks, particularly with longer use 4, 5
  • Renal effects, especially in patients with kidney disease 4
• Safety precautions when prescribing NSAIDs:
  • Use the lowest effective dose for the shortest duration necessary 1
  • Consider cardiovascular and gastrointestinal risk factors before prescribing 1
  • Monitor for side effects including stomach pain, nausea, and dizziness 4, 5

Second-Line Options for Persistent Pain

• If NSAIDs and acetaminophen are ineffective or contraindicated, consider:
  • Tricyclic antidepressants (such as amitriptyline) for chronic low back pain, which show good evidence of effectiveness 1, 2
  • Duloxetine, which provides small to moderate improvements in pain intensity and function 2, 6
  • Tramadol as an option for severe pain not controlled with first-line medications 1

Special Considerations for Radicular Pain

• For back pain with radicular symptoms (sciatica), consider gabapentin which shows fair evidence of effectiveness 1, 2
• NSAIDs are still appropriate for the inflammatory component of radicular pain 2
• Systemic corticosteroids are not recommended for low back pain with or without radicular symptoms as they have been shown to be ineffective 1, 2

Medication to Avoid

• Systemic corticosteroids have good evidence showing they are ineffective for low back pain 1, 2
• Long-term opioid use should be avoided due to limited evidence of effectiveness and substantial risks of abuse, addiction, and adverse effects 1, 6
• Benzodiazepines should be used with caution due to risks of dependence and sedation 2

Treatment Algorithm

1. Start with an NSAID (naproxen or ibuprofen) at the lowest effective dose 1, 7
2. If NSAIDs are contraindicated or poorly tolerated, use acetaminophen 1
3. For acute exacerbations with muscle spasm, add a short-term muscle relaxant 1
4. If pain persists beyond 4-6 weeks or has significant neuropathic features:
   • Consider adding tricyclic antidepressants for chronic pain 1, 2
   • For radicular symptoms, consider gabapentin 2
5. For severe pain not responding to above measures, tramadol may be considered for short-term use 1

Important Caveats

• Most medication trials for back pain are short-term (≤4 weeks), so long-term efficacy and safety data are limited 1
• The benefits of medications for back pain are generally moderate (10-20 points improvement on a 100-point pain scale) 1
• Non-pharmacological approaches such as exercise therapy and physical therapy should be used concurrently with medication 1, 7
• Avoid bed rest as it can worsen outcomes; instead, encourage continued activity as tolerated 1, 6