NSAID Treatment for Sciatica
NSAIDs provide modest benefit over placebo for sciatica, but the evidence is weak and the risk-benefit ratio must be carefully considered given the increased risk of adverse effects.
Evidence Quality and Efficacy
The evidence supporting NSAIDs for sciatica is surprisingly limited. A 2016 Cochrane systematic review found very low-quality evidence that NSAIDs provide no significant pain reduction compared to placebo (mean difference -4.56 points on a 0-100 scale, 95% CI -11.11 to 1.99) 1. However, there was low-quality evidence that NSAIDs show better global improvement than placebo (RR 1.14,95% CI 1.03 to 1.27) 1. The trials were small, had inconsistent results, high risk of bias, and short follow-up periods 1.
Recommended NSAID Dosing
When NSAIDs are prescribed for sciatica, use maximum tolerated and approved dosages for the specific agent chosen:
Ibuprofen
- 400 mg every 4-6 hours as needed (do not exceed 3200 mg/day total) 2
- Doses greater than 400 mg per administration were no more effective than 400 mg in controlled trials 2
- Take with meals or milk if gastrointestinal complaints occur 2
Naproxen
- 500 mg twice daily is the standard dose being evaluated in ongoing sciatica trials 3
Indomethacin
- 25 mg three times daily is a commonly used starting dose 4
- Continue until pain is controlled, then rapidly reduce to complete cessation 4
Treatment Algorithm
For acute sciatica (pain radiating below the knee with nerve root signs):
First-line: Trial NSAIDs at maximum tolerated dose for at least 1 month before declaring treatment failure 5
GI risk modification:
- For patients with increased gastrointestinal risk, use selective COX-2 inhibitors OR non-selective NSAIDs plus gastroprotective agents (proton pump inhibitors) 7, 4
- Consider baseline assessment of blood pressure, renal function (BUN, creatinine), liver function tests, CBC, and fecal occult blood for long-term use 4
Cardiovascular risk assessment:
If NSAIDs fail or are contraindicated:
- Consider gabapentin (start 300 mg once daily, titrate up to 900 mg three times daily) for neuropathic pain component 8
- Intravenous lidocaine (5 mg/kg over 2 hours) showed significant pain reduction in one trial, though this is not standard practice 9
- For isolated active sacroiliitis, consider local glucocorticoid injections with imaging guidance 5
Critical Safety Considerations
NSAIDs carry significant risks that often outweigh modest benefits:
- Increased adverse effects: Risk ratio 1.40 (95% CI 1.02 to 1.93) compared to placebo 1
- Gastrointestinal: Gastric upset, nausea, peptic ulcer, GI bleeding 4
- Renal: Fluid retention, worsened renal function—especially in pre-existing kidney disease 7, 4
- Cardiovascular: Hypertension, potential cardiovascular events 7, 4
Discontinue NSAIDs if:
- BUN or creatinine doubles 4
- Hypertension develops or worsens 4
- Liver function tests increase to three times upper limit of normal 4
What NOT to Do
- Avoid systemic glucocorticoids for axial/radicular pain—strongly recommended against 6, 5
- Avoid long-term continuous NSAID use without clear benefit; switch to on-demand dosing once stable 6, 5
- Do not use doses above maximum approved limits (e.g., >3200 mg/day ibuprofen) 2
Common Pitfalls
The most common error is overestimating NSAID efficacy for sciatica. Unlike inflammatory arthropathies where NSAIDs are clearly beneficial, the evidence for sciatica shows minimal pain reduction with increased side effects 1. Many patients receive prolonged NSAID courses without benefit, accumulating cardiovascular and gastrointestinal risk. Reassess at 2-4 weeks; if no improvement, consider alternative treatments rather than continuing ineffective NSAIDs 6, 7.