What is the best nonsteroidal anti-inflammatory drug (NSAID) for treating sciatica?

Best NSAID for Sciatica

No specific NSAID has been proven superior to others for treating sciatica—choose based on the patient's gastrointestinal, cardiovascular, and renal risk profile rather than expecting differential efficacy. 1

Evidence for NSAID Efficacy in Sciatica

The evidence for NSAIDs in sciatica is surprisingly weak:

• NSAIDs provide no statistically significant pain reduction compared to placebo for sciatica specifically (mean difference -4.56 points on 0-100 scale, 95% CI -11.11 to 1.99), based on very low-quality evidence from a 2016 Cochrane review. 2, 3

• NSAIDs do show modest benefit for global improvement compared to placebo (RR 1.14,95% CI 1.03 to 1.27), though this is based on low-quality evidence. 2, 3

• NSAIDs may be slightly less effective for sciatica than for non-radicular low back pain, as the neuropathic component of sciatic pain responds poorly to anti-inflammatory mechanisms. 4

• Despite limited efficacy data, the American College of Physicians still recommends NSAIDs as first-line pharmacological treatment for low back pain with sciatica. 1, 4

Selecting the Appropriate NSAID

Since no NSAID demonstrates superior efficacy for sciatica, base your selection entirely on safety considerations: 1

For Patients with Low GI Risk:

• Start with ibuprofen 1200 mg daily (divided doses), which has the lowest gastrointestinal risk profile among NSAIDs while providing equivalent pain relief. 5
• Naproxen is an alternative with intermediate GI risk. 5

For Patients with High GI Risk:

• Use a non-selective NSAID plus proton pump inhibitor, or select a COX-2 inhibitor (with or without gastroprotection). 1, 5
• GI risk factors include: age >65, history of ulcers, concurrent anticoagulation, or corticosteroid use. 5

Cardiovascular Considerations:

• Assess cardiovascular risk before prescribing any NSAID, as most NSAIDs (both COX-2 selective and non-selective) increase myocardial infarction risk. 1
• Use the lowest effective dose for the shortest duration necessary. 1

Renal Considerations:

• Monitor renal function in patients with pre-existing kidney disease, as all NSAIDs carry renovascular risks. 1

Optimal Treatment Algorithm for Sciatica

Step 1: Initial NSAID Trial

• Prescribe ibuprofen 1200 mg daily (or alternative NSAID based on risk profile) for 2-4 weeks. 1, 4
• For persistently active symptoms, continuous NSAID treatment is preferred over on-demand dosing. 1

Step 2: Address the Neuropathic Component

Since sciatica is a mixed pain syndrome with both nociceptive and neuropathic components: 6

• Add gabapentin (titrated to 1200-3600 mg/day) specifically for the radicular/neuropathic pain component, as it shows small to moderate short-term benefits for radiculopathy. 1, 7, 4
• Gabapentin is particularly effective when NSAIDs alone provide insufficient relief. 7, 6

Step 3: Consider Adjunctive Muscle Relaxants

• For acute exacerbations with muscle spasm, add a short-term muscle relaxant (≤1-2 weeks) such as cyclobenzaprine or tizanidine. 7, 4
• Combining NSAIDs with muscle relaxants increases central nervous system adverse events (sedation, dizziness), so use cautiously. 1, 4

Step 4: Alternative for Chronic Symptoms

If NSAIDs remain insufficient after 4-6 weeks:

• Add a tricyclic antidepressant (amitriptyline) for moderate efficacy in chronic pain with neuropathic features. 1, 7, 4
• Consider duloxetine as an alternative, particularly if depression coexists. 7

Critical Pitfalls to Avoid

• Do NOT use systemic corticosteroids for sciatica—they show no superiority over placebo and carry significant adverse effects. 1, 4

• Do NOT expect NSAIDs alone to adequately treat sciatica, as the neuropathic component requires different pharmacological approaches (gabapentin, tricyclic antidepressants). 7, 6

• Do NOT prescribe muscle relaxants beyond 2 weeks—no evidence supports efficacy for chronic use, and they carry risks of sedation, falls (especially in elderly), and tolerance. 7

• NSAIDs carry increased adverse effect risk compared to placebo (RR 1.40,95% CI 1.02 to 1.93), including GI bleeding, cardiovascular events, and renal dysfunction. 2, 3

• Reassess efficacy regularly—if no improvement occurs within 2-4 weeks of NSAID therapy, escalate to combination therapy rather than continuing ineffective monotherapy. 7