What is the best course of action for a patient with elevated blood pressure, presenting with lower back and right hip pain that started after walking, who is requesting a renewal of their ibuprofen (nonsteroidal anti-inflammatory drug)?

Management of Lower Back and Hip Pain with Elevated Blood Pressure and Ibuprofen Request

Do not renew the ibuprofen prescription for this patient with elevated blood pressure, as NSAIDs including ibuprofen can worsen hypertension and interfere with antihypertensive therapy. 1, 2

Immediate Blood Pressure Management

• Confirm the elevated blood pressure with repeat measurements at the same visit or within days, as a single elevated reading may not represent true hypertension 3
• If BP is ≥160/100 mmHg, confirm within days to weeks, preferably with home or ambulatory monitoring 3
• If BP is ≥180/110 mmHg, exclude hypertensive emergency immediately 3
• Initiate or optimize antihypertensive therapy before considering any analgesic that could worsen blood pressure control 1

Why Ibuprofen Should Be Avoided

NSAIDs including ibuprofen can lead to new-onset hypertension or worsening of pre-existing hypertension, which may contribute to increased cardiovascular events 1. The evidence is compelling:

• Ibuprofen causes significant blood pressure increases in hypertensive patients: mean increases of 6.4 mmHg in supine diastolic BP and 6.6 mmHg in supine mean arterial pressure after just 3 weeks of treatment 2
• Ibuprofen interferes with the efficacy of antihypertensive drugs, particularly diuretics, beta-blockers, and ACE inhibitors 1, 4, 2
• Indomethacin, naproxen, and piroxicam have the greatest pressor effect among NSAIDs, while ibuprofen has an intermediate blood pressure effect 4, 5
• The FDA explicitly warns that NSAIDs should be used with caution in patients with hypertension, and blood pressure should be monitored closely during NSAID treatment 1

Alternative Pain Management Strategy

For acute or subacute lower back pain (< 3 months), first-line treatment should be acetaminophen combined with patient education to remain active 6. However, note that acetaminophen has limited efficacy for low back pain based on recent evidence 7.

Non-Pharmacological Options (Preferred)

• Spinal manipulation is recommended for acute low back pain with moderate-quality evidence 6
• Exercise therapy has similar analgesic effects to oral NSAIDs for musculoskeletal pain, with an excellent safety profile and no blood pressure effects 6
• Patient education about expected course and advice to remain active 6

Pharmacological Alternatives if Needed

For pain with radicular features (hip pain radiating down the leg):

• Gabapentin (titrated to 1200-3600 mg/day) shows small to moderate short-term benefits specifically for radicular pain/sciatica 8
• Monitor for sedation, dizziness, and peripheral edema; adjust dosing in renal impairment 8

For nonspecific low back pain without radiculopathy:

• Tricyclic antidepressants (e.g., amitriptyline) provide moderate pain relief for chronic low back pain 8
• Skeletal muscle relaxants (e.g., cyclobenzaprine) are effective for acute low back pain with moderate short-term benefits, but should only be used for ≤1-2 weeks due to sedation and lack of long-term efficacy data 8

Combination approach for mixed pain:

• Start with acetaminophen for the inflammatory component 6
• Add gabapentin if radicular features are present 8
• Consider short-term muscle relaxant for acute exacerbations 8

Medications to Avoid

• Systemic corticosteroids are not recommended for low back pain with or without sciatica, as they are ineffective compared to placebo 8
• Benzodiazepines should be avoided due to risks of abuse, addiction, and lack of efficacy for radiculopathy 8
• Opioids have limited evidence for short-term modest effects and significant adverse effects including nausea, dizziness, constipation, and somnolence 8

Clinical Algorithm

1. Measure and confirm elevated blood pressure (repeat at same visit or schedule follow-up within days) 3
2. Discontinue ibuprofen immediately due to pressor effects and interference with antihypertensive therapy 1, 2
3. Initiate or optimize antihypertensive therapy targeting BP <130/80 mmHg 3
4. Assess pain characteristics: Is there radicular pain (radiating below the knee in sciatic distribution)? 6
   • If yes: Consider gabapentin for neuropathic component 8
   • If no: Start with acetaminophen and non-pharmacological approaches 6
5. Implement non-pharmacological therapy: spinal manipulation for acute pain, exercise therapy for chronic/subacute pain 6
6. Monitor blood pressure closely during any analgesic therapy adjustments 1
7. Reassess pain and function at 2-4 weeks; if no improvement, consider adding tricyclic antidepressant or duloxetine 8

Critical Pitfalls to Avoid

• Do not prescribe NSAIDs to patients with uncontrolled hypertension or those at high cardiovascular risk 1
• Do not use muscle relaxants beyond 1-2 weeks, as there is no evidence for long-term efficacy and risk of tolerance increases 8
• Do not obtain routine imaging for nonspecific low back pain without red flags (severe/progressive neurologic deficits, suspected serious underlying conditions) 6
• Do not assume pain is causing the elevated blood pressure and delay treatment; while acute pain can raise BP, chronic pain's effect is less clear, and NSAIDs independently worsen hypertension 4, 9