Anti-inflammatory Medication (NSAIDS) For Low Back Pain


Treatment Ratings


RISK: 2/5

The American Heart Association and other national and international organizations have warned about chronic use of NSAIDs particularly in patients with, or at risk of developing, cardiovascular disease.

Common side of effects of NSAIDs include nausea and vomiting, diarrhea and reduced appetite, upset stomach, mild heartburn. Other common side effects include bloating, gas, diarrhea, drowsiness, rash and headache, dizziness, constipation, nervousness, mild itching and ringing in the ears.

A common and potentially serious side effect of NSAIDS are gastric or peptic ulcers, which can lead to potentially fatal bleeding. NSAIDs can also cause kidney, liver and cardiovascular side effects. Ibuprofen can increase your risk of fatal heart attack or stroke, especially if you use it long term or take high doses, or if you have heart disease. Do not use this medicine just before or after heart bypass surgery (coronary artery bypass graft, or CABG).

People with cardiovascular or kidney disease, prior heart attacks, prior stroke or history of peptic ulcer should avoid NSAIDs. Do not take more than your recommended dose. An ibuprofen overdose can damage your stomach or intestines. The maximum amount of ibuprofen for adults is 800 milligrams per dose or 3200 mg per day (4 maximum doses). Use only the smallest amount needed to get relief from your pain, swelling, or fever.

The risk of death from bleeding attributed to NSAID/aspirin use is about 5.57% or about 21-25 cases per million people. Interestingly, up to one third of all deaths from NSAIDs/aspirin are from low dose aspirin. Many patients feel that over the counter non-steroidal anti-inflammatory drugs (NSAIDS) like Motrin, Aspirin and similar drugs are very safe, since they are so widely used. This study demonstrates that NSAIDS and aspirin carry a significant risk of injury, primarily from gastric bleeding, and death.
Am J Gastroenterol. 2005 Aug;100(8):1685-93. A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal antiinflammatory drug use.

In reviewing data on the safety of aspirin and other NSAIDs in overdose fatality reports from the American Association of Poison Control Centers (AAPCC), the data indicate that ibuprofen in overdose is relatively benign and requires supportive and symptomatic treatment. However, acute overdose with aspirin and chronic aspirin toxicity (eg, salicylism) are associated with significant morbidity and mortality.

There are reported estimates of 100,000 hospitalizations per year in the U.S. for NSAIDS related gastrointestinal (GI) bleeding alone, and up to 16,500 deaths per year. Risks include gastric bleeding, cardiovascular problems and kidney problems. The cost for caring for these side effects is estimated at $4 billion dollars a year for the elderly alone, though they are not the only ones at risk. All NSAIDS have risks, and you are 2.5 times more likely to have an adverse GI event if you take NSAIDS than if you don’t. You have a 2.4 times greater risk of stroke and triple the risk of kidney failure if you take NSAIDS.

While the risks are greater the longer you take them and in higher doses, NSAID risks are there even if you use them for a short period of time. For some patients the risks GI injury can be reduced by taking a proton-pump inhibitor or misoprostol (which is also used to induce abortion.)

Fine M Quantifying the Impact
Chou Pharm Management of LB E


A large scientific review of a number of studies found that no one NSAID appears more effective than others. Interestingly they also found that using NSAIDs was no more effective than non-pharmacologic interventions (spinal manipulation, physical therapy, bed rest). NSAIDS appear to be slightly better at relieving back pain than paracetamol (acetaminophen) but had a lot more side effects. Another study released in 2015 showed paracetamol was no more effective than placebo for low back pain. Some NSAIDs are used for more severe or acute pain (such as ketorolac) while others, such as aspirin, are also used for their blood thinning effects.


Fine M Quantifying the Impact
Chou Pharm Management of LB

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, Mar 2016A guideline from the American Pain Society and American College of Physicians rates NSAIDS as having moderate effectiveness, though no one type of NSAID was proven better than others. They gave NSAIDS a grade of “moderate” in terms of effectiveness for both acute and chronic pain.



While there are prescription NSAIDS available, most commonly used NSAIDS, such as ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve) and aspirin are readily available almost everywhere and over the counter. Generic NSAIDS like these are very inexpensive, and this treatment is widely used in the US.


COST 3/5

A recent consumer report demonstrated an enormous range in prices for NSAIDs, ranging from about $15 for a month’s supply of generic ibuprofen up to $1700 for a mefenamic acid prescription. Typically generic ibuprofen or naproxen represent best values. If your physician prescribes a more expensive anti-inflammatory, ask if a less expensive version would work as well.

DRUG                                  DOSAGE               PRICE          QUANTITY

Ibuprofen (generic)            200mg                   $2.48               100

Advil                                      200mg                    $7.99               100

Naproxen (generic)            220mg                    $9.49               150

Celecoxib (Celebrex)          100 mg                    $219                60

Diclofenac (Voltaren)         25 mg capsule        $412               120

Aspirin (Bufferin)                  325 mg                  $4.98              130

Aspirin (Bayer)                       325 mg                  $11.79             200

Obviously prices can vary from very inexpensive ($) to very expensive ($$$$$), depending on whether you use a generic, over the counter brand or a prescription brand.


USEFULNESS (overall rating): 4/5

NSAIDS are among the most commonly used drugs in the United States, and can be found in most people’s medicine cabinets. They are moderately effective for both acute and chronic low back pain, however their use carries significant risks. Costs vary wildly, but most people have access to inexpensive generics, making NSAIDS a particularly useful treatment approach to low back pain.



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