What is the preferred Non-Steroidal Anti-Inflammatory Drug (NSAID) for treating back pain in older women, ibuprofen or diclofenac?

Ibuprofen vs Diclofenac for Back Pain in Older Women

For back pain in older women, acetaminophen should be the first-line treatment, but if an NSAID is necessary, ibuprofen is preferred over diclofenac due to better cardiovascular and renal safety profiles in this population. 1

First-Line Approach: Avoid NSAIDs When Possible

• Acetaminophen (up to 4g/24 hours) is recommended as initial and ongoing pharmacotherapy for musculoskeletal pain in older adults due to its superior safety profile compared to NSAIDs, with no significant gastrointestinal bleeding, adverse renal effects, or cardiovascular toxicity. 1

• Before prescribing any NSAID, clinicians should optimize acetaminophen dosing—sometimes increasing to 1,000 mg per dose provides adequate relief without requiring stronger medications. 1

When NSAIDs Are Necessary: Choose Ibuprofen Over Diclofenac

Evidence Supporting Ibuprofen

• NSAIDs should be used "rarely and with extreme caution" in older adults, only when safer therapies have failed and with ongoing assessment of risks. 1

• Patients taking aspirin for cardioprophylaxis should not use ibuprofen due to drug interactions that reduce aspirin's cardioprotective effects. 1

• Ibuprofen demonstrated comparable efficacy to diclofenac for acute low back pain, with 62% of patients achieving mild or no pain at 5 days. 2

Evidence Against Diclofenac in Older Women

• Topical diclofenac was less efficacious than oral ibuprofen for acute musculoskeletal low back pain, with improvement scores of 6.4 versus 10.1 on the Roland Morris Disability Questionnaire. 3

• While diclofenac 150mg/day showed superior efficacy to ibuprofen 1200mg/day in osteoarthritis trials, these studies did not specifically address the elderly population or account for cardiovascular and renal risks that are particularly concerning in older women. 4

Absolute and Relative Contraindications in Older Women

Absolute Contraindications to All NSAIDs

• Current active peptic ulcer disease 1
• Chronic kidney disease (moderate level of evidence) 1
• Heart failure 1

Relative Contraindications Requiring Extreme Caution

• Hypertension 1
• History of peptic ulcer disease or Helicobacter pylori infection 1
• Concomitant use of corticosteroids or SSRIs 1
• Patients on angiotensin-converting enzyme inhibitors, diuretics, or antiplatelets due to drug interactions 1

Mandatory Co-Prescriptions and Monitoring

• All patients taking NSAIDs must receive a proton pump inhibitor or misoprostol for gastrointestinal protection. 1

• Patients must be routinely assessed for gastrointestinal and renal toxicity, hypertension, heart failure, and drug-drug interactions. 1

• Renal function should be monitored every 3-6 months, or 1-2 weeks after starting NSAIDs. 5

Dosing Recommendations When NSAIDs Are Used

• Use the lowest effective dose for the shortest duration possible—ideally ≤2 weeks for acute pain. 1

• For ibuprofen: Start with 200-400mg every 6-8 hours as needed, maximum 1200mg/day in older adults. 6, 2

• Never prescribe more than one NSAID simultaneously. 1

Alternative Approaches to Consider First

Topical NSAIDs

• Topical diclofenac gel should be strongly preferred over oral NSAIDs if pain is localized, due to minimal systemic absorption and high safety profile. 1, 5

Multimodal Analgesia

• A multimodal approach including acetaminophen, gabapentinoids for radicular pain, lidocaine patches, and tramadol is recommended before escalating to continuous NSAID use. 1

• Physical therapy, spinal manipulation, massage therapy, and cognitive behavioral therapy should be implemented alongside any medication. 5

Critical Pitfalls to Avoid

• Do not assume NSAIDs are safe in older women—age-related decreases in glomerular filtration rate result in decreased excretion and increased risk of renal toxicity. 1

• Do not prescribe NSAIDs for chronic daily use—they are intended for short-term management only in this population. 1

• Do not overlook "hidden sources" of NSAIDs in combination products or over-the-counter medications the patient may already be taking. 1

• Acute kidney injury and gastrointestinal complications are the primary concerns with NSAID use in elderly patients, particularly in those with hip fractures or trauma where NSAIDs are generally not recommended. 1