Pharmacologic Management of Acute Low Back Pain
For adults with acute low back pain without red flags, start with NSAIDs as first-line pharmacologic therapy, providing approximately 10 points greater pain relief on a 100-point scale compared to acetaminophen, with moderate-quality evidence supporting their effectiveness. 1
First-Line Medication Options
NSAIDs are the most effective first-line choice, offering moderate short-term pain relief with stronger evidence than alternatives. 1, 2 Use the lowest effective dose for the shortest duration necessary. 1
Acetaminophen (up to 4g daily) is a reasonable alternative with a more favorable safety profile and lower cost, though slightly less effective than NSAIDs. 1, 2 This is appropriate for patients who cannot tolerate NSAIDs or have contraindications. 1
Before prescribing NSAIDs, assess cardiovascular and gastrointestinal risk factors. 1 Consider co-administration with a proton-pump inhibitor in higher-risk patients and monitor for gastrointestinal and renal toxicity, especially in those with pre-existing kidney disease. 1
Second-Line and Adjunctive Options
Skeletal muscle relaxants may be added if NSAIDs or acetaminophen alone provide inadequate relief, with moderate-quality evidence supporting their use in acute low back pain. 1 However, be aware of sedation as a common side effect. 1
Duloxetine 60 mg daily is a second-line option when pain persists despite first-line therapy, particularly if a neuropathic component is present. 3, 1
Medications to Avoid
Systemic corticosteroids should not be used for low back pain—good-quality evidence demonstrates no benefit over placebo. 3, 1
Benzodiazepines are not recommended due to high sedation rates and increased fall risk. 3, 1
Opioids (including tramadol) should only be considered judiciously for severe, disabling pain uncontrolled by acetaminophen and NSAIDs, with time-limited courses as a last resort. 1, 2 Reserve opioids strictly for breakthrough pain unresponsive to all other strategies, using the lowest effective dose for the briefest period. 3
Essential Non-Pharmacologic Measures
Advise patients to stay active and avoid bed rest, as maintaining activity reduces disability and improves outcomes. 1, 2, 4 Bed rest should be avoided if possible. 2
Apply superficial heat (heating pads) to the lumbar region—moderate-quality evidence supports its benefit for acute low back pain. 3, 1
Provide reassurance and self-care education, emphasizing that most acute low back pain is self-limited and improves within a month regardless of treatment. 1, 2, 5
Critical Monitoring and Follow-Up
Reassess at 1 month if symptoms persist without improvement; consider earlier reevaluation in patients over 65 years, those with signs of radiculopathy, or worsening symptoms. 1
Most pharmacologic benefits are short-term only—avoid long-term medication use without clear ongoing benefit. 1
Screen for psychosocial risk factors (depression, catastrophizing, fear-avoidance beliefs) that predict progression to chronic disabling pain. 3, 6
Key Pitfalls to Avoid
Do not routinely order imaging for uncomplicated acute low back pain without red flags—it provides no clinical benefit and exposes patients to unnecessary radiation. 1, 6, 2
Do not exceed maximum safe acetaminophen dose (4g/24h), especially when using combination products containing opioids. 3
Avoid prescribing prolonged bed rest—maintaining activity within pain-limited thresholds is essential for recovery. 3, 1