NSAIDs: Non-Steroidal Anti-Inflammatory Drugs

Because most episodes of back pain [4] have inflammation as a contributing factor, anti-inflammatory medication such as non-steroidal anti-inflammatory drugs (NSAIDs) is often an effective pain medication treatment option [5].

The types of NSAIDs reviewed on this page work like aspirin by limiting the formation of inflammation, but have fewer gastrointestinal side effects (such as gastritis or ulcers) than aspirin.

Most Common Types of NSAID’s

NSAIDs comprise a large class of drugs with many different options. In addition to aspirin, there are currently several types of both non-prescription (over-the-counter) NSAIDs and prescription brands of NSAIDs. The three types of NSAIDs most commonly used to treat many types of back pain and neck pain include:

• Ibuprofen (e.g. brand names Advil, Motrin, Nuprin)
• Naproxen (e.g. brand names Aleve, Naprosyn)
• COX-2 inhibitors (e.g. brand name Celebrex [6])

The type of NSAID recommended will usually depend on a number of factors, including the patient’s diagnosis, clinical situation and level of pain, individual risk factors, and the patient’s past experience with particular medications.

Ibuprofen (e.g. Advil, Motrin, Nuprin)

Ibuprofen was one of the original non-steroidal anti-inflammatory drugs and is available without a prescription. For patients with back problems, ibuprofen is most commonly recommended to relieve mild or moderate back pain, tenderness, inflammation, and stiffness. Common situations in which ibuprofen may be recommended include:

• Activity-related pain or discomfort (e.g. pain that follows sports, housework, shoveling snow, or other exertion)
• Pain related to muscle strain in the low back
• Neck stiffness related to muscle, ligament or tendon strains or damage

Ibuprofen does have some aspirin-like effects on the stomach, so people with active ulcers or sensitive stomachs should avoid ibuprofen. It is best to take ibuprofen with food to minimize the chance of stomach upset. Ibuprofen also has a mild blood thinning effect that lasts a few hours, and can reduce the effectiveness of some blood pressure medications and diuretics (water pills).

The typical recommended dose for ibuprofen is 400 mg taken every eight hours. Prescription doses can be as high as 800 mg of ibuprofen every eight hours.

Naproxen (e.g. Aleve, Naprosyn, Anaprox, Naprelan)

Naproxen is available in both non-prescription strength (e.g. brand name Aleve) and prescription strength (e.g. brand name Naprosyn). For patients with back pain, it works by reducing proteins that cause inflammation and pain in the body and is commonly recommended for treatment of back pain.

Naproxen thins the blood, so individuals taking oral blood thinners or anticoagulants should avoid naproxen, as excessive blood thinning may lead to bleeding. Naproxen also can have some adverse gastrointestinal side effects, so people with active ulcers or sensitive stomachs should avoid it. It is best to take naproxen with food to reduce the chance of upset stomach. Notably, naproxen has a potentially fatal interaction with MAOI drugs (e.g. Marplan, Nardil).

The usual adult dose is 250 to 500 mg twice daily using regular naproxen tablets.

COX-2 inhibitors (e.g. prescription brand Celebrex)

This is a newer class of NSAID, which includes the brand name Celebrex [7]. It works  by stopping the chemical reaction that leads to inflammation in the body, but (unlike other NSAIDs) does not harm the chemical production of the protective stomach lining. Therefore, COX-2 inhibitors lead to a lower gastrointestinal complication rate than other NSAIDs and do not tend to produce ulcers.

Also unlike other NSAIDs, COX-2 inhibitors do not impair blood clotting, so they are considered safer for patients taking blood thinning medications, such as warfarin (e.g. Coumadin), and they may be used before or after surgery without an increased risk of bleeding.

Important new information from recent studies shows a potentially increased risk for cardiovascular events (such as heart attack and stroke) for COX-2 inhibitors, and the FDA has called for further research. Patients taking COX-2 inhibitors should meet with their physician to determine their individual risk factors for side effects [8] and appropriate treatment options.

Other forms of NSAID’s

In addition to the above, NSAID's come in forms other than taking it orally. For example:

• Toradol can be given as an intravenous drug, so it is useful after surgery or if the patient cannot eat.
• Flector can be given as a transcutaneous form of Diclofenac. An NSAID administered through an adhesive patch applied to the skin can be useful because it does not give the patient a large dose of the drug systematically, which can reduce gastrointestinal and other potential side effects of NSAIDs.

Effective use of NSAIDs

It is better to use NSAIDs continuously to build up an anti-inflammatory blood level, and the efficacy is markedly lower if taken only when experiencing pain. Taking the drug regularly in the prescribed/recommended dose lets the drug build up over time in order to have an anti-inflammatory effect and allowing the area a better healing environment.

NSAIDs and the pain relief medication acetaminophen [9] (e.g.

brand name Tylenol) work differently, so sometimes doctors recommend taking the two medications at the same time. Some people report feeling better pain relief when they take both an NSAID and acetaminophen for their pain.