What is the recommended dosage of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for acute inflammatory back pain?

Recommended Dosage for Acute Inflammatory Back Pain

For acute inflammatory back pain, NSAIDs are recommended as first-line medication at the lowest effective dose for the shortest duration possible, with acetaminophen (up to 4g/day) as an alternative first-line option for patients with cardiovascular risk factors. 1, 2

First-Line Treatment: NSAIDs

• NSAIDs are slightly more effective than placebo for short-term pain reduction and functional improvement in acute low back pain 3
• Use the lowest effective dose for the shortest duration necessary to minimize adverse effects 1
• Standard NSAID dosages for acute inflammatory back pain:
  • Diclofenac: 150 mg daily (equivalent dose) 4
  • Naproxen: 1000 mg daily 4
  • Ibuprofen: 2400 mg daily (typically 800 mg three times daily) 4
  • Celecoxib: 400 mg daily 4

Alternative First-Line Option: Acetaminophen

• Acetaminophen (up to 4g/day) is a reasonable first-line option, particularly for patients with cardiovascular risk factors 1, 2
• Slightly weaker analgesic than NSAIDs but has a more favorable safety profile 1
• Standard dosage: Up to 4g daily (typically 1000 mg every 6 hours) 1

Second-Line Treatment: Muscle Relaxants

• Consider for short-term relief when NSAIDs or acetaminophen provide inadequate pain control 1
• Associated with central nervous system adverse effects, primarily sedation 1
• No compelling evidence that one muscle relaxant is more effective than others 1

Third-Line Treatment: Opioids

• Only consider for severe, disabling pain not controlled with acetaminophen and NSAIDs 1
• Short-acting opioid formulations with recommended starting doses 1:
  • Hydrocodone/APAP: 5-15 mg every 4-6 hours as needed
  • Oxycodone: 5-15 mg every 4-6 hours as needed
  • Tramadol: 50 mg every 4-6 hours 1

Important Considerations

• NSAIDs are associated with gastrointestinal, renal, and cardiovascular risks 1
• For patients with cardiovascular risk factors, acetaminophen should be preferred over NSAIDs 2
• Recent research shows no significant difference in functional outcomes between ibuprofen, ketorolac, and diclofenac for acute low back pain, though ketorolac may provide better pain relief with less stomach irritation 5
• Adding muscle relaxants or opioids to NSAIDs does not appear to improve functional outcomes compared to NSAIDs alone 6

Monitoring and Precautions

• Assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs 1
• Consider co-administration with a proton-pump inhibitor in higher-risk patients 1
• Monitor for central nervous system effects with muscle relaxants 1
• Limit opioid prescriptions to the lowest practical dose for a limited duration (e.g., 1 week) 1
• Regular reassessment of pain control and medication effectiveness is essential 2

Treatment Algorithm

1. Start with NSAIDs at recommended doses for most patients without contraindications 1, 3
2. For patients with cardiovascular risk factors, start with acetaminophen up to 4g/day 2
3. If inadequate relief, consider adding a short-term muscle relaxant 1
4. For severe, disabling pain unresponsive to above measures, consider short-term opioids at the lowest effective dose 1
5. Reassess regularly and discontinue medications as soon as possible 2