What is the recommended anti‑inflammatory treatment for sciatica, including first‑line NSAIDs, dosing, contraindications, and alternative options?

Anti-Inflammatory Treatment for Sciatica

NSAIDs provide modest benefit for global improvement in sciatica but show no significant advantage over placebo for pain reduction, and their use must be weighed against increased risk of adverse effects. 1

First-Line NSAID Therapy

For patients with sciatica, prescribe NSAIDs at full therapeutic doses rather than on-demand dosing, despite limited evidence of efficacy specifically for sciatica. 1

Recommended NSAID Options and Dosing

• Naproxen 500 mg twice daily is a reasonable first choice, as it is currently being studied in a large placebo-controlled trial for sciatica and has established safety data 2
• Ibuprofen 600 mg four times daily (up to 2400 mg/day) is an alternative option with lower cost 3
• Diclofenac 50 mg three times daily can be considered, though it carries higher hepatotoxicity risk 3
• No specific NSAID has proven superior efficacy over others for sciatica 1

Duration of Treatment

• Prescribe NSAIDs for 10-14 days initially to assess response 2
• Continue treatment only if meaningful improvement occurs, as prolonged use increases adverse effect risk 3, 1

Critical Contraindications and Precautions

Absolute contraindications to NSAIDs include: 3, 4

• Active peptic ulcer disease or history of NSAID-associated GI bleeding
• Severe renal impairment (eGFR <30 mL/min)
• Recent myocardial infarction or stroke
• Decompensated heart failure
• Known hypersensitivity to NSAIDs or aspirin-induced asthma

High-Risk Patients Requiring Gastroprotection

For patients with increased GI risk who require NSAIDs, co-prescribe a proton pump inhibitor (PPI) or use celecoxib 200 mg twice daily. 3

High-risk features include: 3

• Age >65 years
• History of peptic ulcer disease
• Concurrent corticosteroid use
• Concurrent anticoagulant or antiplatelet therapy

Cardiovascular Risk Considerations

• All NSAIDs carry cardiovascular risk, including increased blood pressure (mean 5 mm Hg elevation) and thrombotic events 3
• Avoid NSAIDs entirely in patients with uncontrolled hypertension or recent cardiovascular events 3
• The cardiovascular risk appears similar across both non-selective NSAIDs and COX-2 inhibitors 3

Alternative and Adjunctive Therapies

When NSAIDs Are Insufficient or Contraindicated

Consider adding gabapentin or pregabalin for the neuropathic pain component of sciatica when NSAIDs provide inadequate relief. 5, 6

• Sciatica represents a "mixed pain syndrome" with both nociceptive and neuropathic components 5
• NSAIDs only address the nociceptive component, explaining their limited efficacy 5
• Gabapentin starting at 300 mg once daily, titrated to 900-1800 mg/day in divided doses has shown benefit in case reports 6
• Anticonvulsants (gabapentin, pregabalin) and tricyclic antidepressants (amitriptyline) target the neuropathic component 5

Simple Analgesics

Acetaminophen (paracetamol) 1000 mg three to four times daily can be used as monotherapy or combined with NSAIDs for additional pain control 3

• Acetaminophen has minimal GI toxicity compared to NSAIDs 3
• It serves as rescue medication when NSAIDs are contraindicated 3

Opioids

• Reserve opioids for severe, refractory pain only 3
• If needed, use immediate-release formulations for short-term management 3
• Avoid long-term opioid therapy for sciatica due to dependence risk and lack of evidence for chronic neuropathic pain

Common Pitfalls to Avoid

• Do not prescribe indomethacin as first-line therapy despite its historical use; it has the highest risk of GI toxicity and CNS side effects among NSAIDs 3, 4
• Do not use systemic corticosteroids for sciatica; they lack evidence for efficacy in radicular pain 3
• Do not continue NSAIDs beyond 2-4 weeks without reassessing benefit versus risk, as the evidence shows only modest global improvement and no significant pain reduction 1
• Do not assume all sciatica pain is purely inflammatory; the neuropathic component often requires different pharmacologic approaches 5

Evidence Quality and Clinical Reality

The evidence for NSAIDs in sciatica is surprisingly weak: 1

• A 2016 Cochrane review found very low-quality evidence that NSAIDs reduce pain compared to placebo (mean difference only -4.56 points on 0-100 scale, not statistically significant)
• Low-quality evidence shows NSAIDs provide better global improvement than placebo (RR 1.14)
• Low-quality evidence demonstrates increased adverse effects with NSAIDs versus placebo (RR 1.40)

Given this limited evidence, the decision to prescribe NSAIDs should prioritize patient safety, using the lowest effective dose for the shortest duration, while actively considering adjunctive neuropathic pain medications. 1