NSAID Selection for 4-Week Course in Acute Low Back Pain
For an adult with uncomplicated acute low back pain requiring a 4-week course, prescribe standard oral NSAIDs such as ibuprofen (400-800 mg every 6 hours, maximum 2.4 g/day), naproxen (500 mg twice daily), or meloxicam (7.5-15 mg once daily), as these are the recommended first-line options with proven efficacy. 1
Recommended NSAID Options
The American College of Physicians specifically recommends these standard oral NSAIDs for outpatient back pain management 1:
- Ibuprofen: 400-800 mg every 6 hours (maximum 2.4 g/day) 1
- Naproxen: 500 mg twice daily 1
- Meloxicam: 7.5 mg once daily, may increase to 15 mg once daily 1
Evidence Supporting NSAID Use
NSAIDs demonstrate moderate superiority over placebo for acute low back pain 2:
- NSAIDs reduce pain intensity by approximately 7 points on a 100-point visual analogue scale compared to placebo, though this effect is small and may not be clinically significant 3
- NSAIDs improve disability scores by approximately 2 points on the Roland-Morris Disability Questionnaire (0-24 scale) compared to placebo 3
- No specific NSAID has been proven superior to others for pain relief 2
Critical Pre-Prescription Risk Assessment
Before prescribing any NSAID, you must assess three key risk domains 1:
- Cardiovascular risk factors: NSAIDs increase risk of myocardial infarction and stroke 2, 1
- Gastrointestinal risk factors: NSAIDs increase risk of bleeding and ulcers 2, 1
- Renal function: Avoid NSAIDs in significant renal impairment 1
For high-risk patients, consider co-administration with a proton-pump inhibitor 2, 1.
Alternative First-Line Option for High-Risk Patients
If cardiovascular, gastrointestinal, or renal risk factors are present, prescribe acetaminophen instead: 1000 mg every 6 hours (maximum 4 g/day) 1, 4. Acetaminophen has a slightly weaker analgesic effect (approximately 10 points less on a 100-point pain scale) but a superior safety profile 2.
Duration and Monitoring Strategy
- Use NSAIDs at the lowest effective dose for the shortest duration necessary 2, 1
- Reassess pain and function after 1-2 weeks 1
- If no improvement after 2-4 weeks, consider non-pharmacologic interventions (spinal manipulation, exercise therapy, cognitive-behavioral therapy) 1
Important Caveat About 4-Week Duration
The evidence base for NSAID use beyond 2 weeks is sparse. Only 6 of 51 trials in the Cochrane review evaluated NSAIDs for longer than 2 weeks, with the longest trial being 6 weeks 2. Most trials focused on short-term use (≤3 weeks) 3. Therefore, while a 4-week course is reasonable, closely monitor for adverse effects and reassess the need for continued therapy at 2 weeks.
What NOT to Prescribe
- Avoid ketorolac for outpatient management—standard oral NSAIDs are preferred 1
- Avoid aspirin due to insufficient evidence for low back pain 2
- Avoid selective COX-2 inhibitors (except celecoxib if specifically indicated) as there is no clear difference in pain reduction compared to non-selective NSAIDs 2