Can a patient use a muscle relaxer and Nonsteroidal Anti-Inflammatory Drug (NSAID)?

Can a Patient Use a Muscle Relaxer and NSAID Together?

Yes, a patient can safely use a muscle relaxer and NSAID together—this combination is appropriate and often more effective than either agent alone for acute musculoskeletal pain, including low back pain and cervical strain. 1, 2

Evidence Supporting Combination Therapy

The combination of a muscle relaxant with an NSAID provides superior pain relief compared to monotherapy for acute musculoskeletal conditions:

• A randomized trial demonstrated that cyclobenzaprine plus naproxen resulted in significantly less objective muscle spasm, less tenderness, and greater range of motion in the lumbosacral spine compared to naproxen alone (P < 0.05) in patients with acute low back pain. 2

• Clinical evidence confirms that combining a muscle relaxant with an NSAID (or COX-2 inhibitor) is superior to single agents alone for treating acute, uncomplicated musculoskeletal disorders. 1

• The American College of Physicians guidelines position NSAIDs as first-line therapy and muscle relaxants as second-line options for short-term relief, with combination therapy being a reasonable approach when monotherapy is insufficient. 3

Important Safety Distinction: Avoid Opioid Co-Prescription

The critical safety concern is NOT about combining muscle relaxants with NSAIDs—it is about combining muscle relaxants (particularly benzodiazepines) with opioids:

• Co-prescribing opioids with benzodiazepines increases mortality risk 3- to 10-fold compared to opioids alone, due to potentiation of respiratory depression. 4

• The FDA issued a black box warning in 2016 specifically against co-prescribing opioids and benzodiazepines. 4

• Emergency medicine guidelines recommend against routinely combining opioids with muscle relaxants/sedative-hypnotics when discharging patients. 4

Practical Prescribing Algorithm

For acute musculoskeletal pain (low back pain, cervical strain, muscle spasm):

1. Start with NSAID monotherapy (e.g., ibuprofen 400-800 mg three times daily, maximum 3200 mg/day). 3

2. Add a non-benzodiazepine muscle relaxant (e.g., cyclobenzaprine 5-10 mg three times daily) if NSAID alone provides insufficient relief. 3, 2

3. Prescribe for short duration only (typically 7-14 days maximum), as muscle relaxants are effective for short-term relief but associated with sedation and other CNS side effects. 4

4. Avoid benzodiazepine muscle relaxants (diazepam, alprazolam, lorazepam) if possible, as they offer no proven superiority and carry higher abuse potential. 4

Key Safety Considerations

When prescribing NSAIDs:

• Assess cardiovascular and gastrointestinal risk factors before prescribing. 3
• Use the lowest effective dose for the shortest necessary duration. 4, 3
• Add a proton pump inhibitor for patients at high GI risk (age >60, history of ulcer, concurrent anticoagulation). 3
• Monitor renal function and blood pressure, especially in patients with preexisting hypertension, renal disease, or heart failure. 4

When prescribing muscle relaxants:

• Warn patients about sedation and drowsiness, which occur in approximately 49% of patients. 3, 2
• Advise against driving or operating machinery until tolerance to sedative effects is established. 2
• Avoid in elderly patients when possible due to increased fall risk and cognitive impairment. 3

Common Pitfalls to Avoid

• Do not assume all muscle relaxants are benzodiazepines—non-benzodiazepine agents like cyclobenzaprine, methocarbamol, and tizanidine are preferred for musculoskeletal pain. 4

• Do not prescribe muscle relaxants for chronic pain—evidence supports their use only for acute pain (less than 4 weeks duration), as they provide no clinically significant benefit for chronic conditions. 4

• Do not combine muscle relaxants with opioids routinely—this combination carries significant mortality risk and lacks evidence of superior efficacy compared to safer alternatives. 4

• Do not use aspirin with NSAIDs for cardioprotection—ibuprofen interferes with aspirin's antiplatelet effect; if both are needed, ibuprofen should be taken at least 30 minutes after or 8 hours before immediate-release aspirin. 4

Evidence Limitations

One randomized trial found no additional benefit when cyclobenzaprine was added to ibuprofen for acute cervical strain in an emergency department setting, though this was a small study (n=61) that may have been underpowered to detect modest differences. 5 However, this single negative trial is outweighed by other evidence supporting combination therapy for acute musculoskeletal conditions. 1, 2