Best NSAID for Back Pain
No single NSAID has been proven superior to others for back pain relief—any NSAID can be used as first-line therapy, with the choice based primarily on safety profile rather than efficacy. 1
Evidence for NSAID Equivalence
Multiple high-quality systematic reviews consistently demonstrate that no specific NSAID outperforms others for pain relief in back pain patients. 1 The Cochrane review analyzing 24 trials found no evidence that any nonselective NSAID is superior to others for pain control. 1 A 2021 head-to-head trial comparing ibuprofen, ketorolac, and diclofenac found no clinically important differences in functional outcomes (RMDQ improvements: ibuprofen 9.4, ketorolac 11.9, diclofenac 10.9; p=0.34). 2
Efficacy of NSAIDs as a Class
NSAIDs are moderately effective for back pain:
For acute low back pain: NSAIDs reduce pain by approximately 8.4 points on a 0-100 scale compared to placebo, with patients 24% more likely to report global improvement. 1
For chronic low back pain: NSAIDs reduce pain by approximately 12.4 points on a 0-100 scale compared to placebo after 12 weeks. 1
For radicular pain/sciatica: Evidence shows no clear benefit of NSAIDs over placebo. 1
Practical Selection Strategy
Since efficacy is equivalent across NSAIDs, select based on the patient's cardiovascular and gastrointestinal risk profile:
First-Line Approach
- Use the lowest effective dose for the shortest duration necessary to minimize adverse effects. 1, 3
- Common options include ibuprofen 600 mg three times daily or diclofenac 50 mg three times daily. 2
Risk-Based Selection
For patients with cardiovascular risk factors: Consider acetaminophen (up to 4g/day) as first-line instead of NSAIDs, despite slightly weaker analgesic effect (approximately 3 points less on 0-100 scale). 1, 3
For patients with gastrointestinal risk: Co-administer a proton-pump inhibitor with the NSAID. 1, 3
For patients with both CV and GI risk: Acetaminophen is preferred over NSAIDs. 3
Important Safety Considerations
- NSAIDs carry well-established gastrointestinal, renal, and cardiovascular risks. 1
- Most NSAIDs (both COX-2 selective and nonselective) are associated with increased myocardial infarction risk. 1
- Adverse event rates in trials appear similar to placebo (RR 1.04), but trials were underpowered to detect serious but less common events. 4
- Long-term safety data for NSAIDs in back pain are sparse—most trials evaluated only 2-6 weeks of therapy. 1
When NSAIDs Fail
If NSAIDs provide inadequate relief:
- Avoid adding acetaminophen to ibuprofen—a 2020 trial showed no additional benefit (both groups improved 11 points on RMDQ). 5
- Muscle relaxants can be considered for short-term use, though evidence is limited. 1, 3
- Reserve opioids only for severe, disabling pain uncontrolled by NSAIDs/acetaminophen, using the lowest dose for the shortest duration (typically 1 week). 1, 3
Bottom Line
Choose any NSAID based on availability, cost, and patient risk factors rather than searching for a "best" option—they are all equally effective. 1 Prioritize safety assessment over NSAID selection, and use the minimum effective dose for the shortest necessary duration. 1, 3