On April 7, 2005 the Food and Drug Administration requested that Pfizer suspend sales of Bextra in the United States. As a result, Bextra will no longer be available to patients in the United States. For more information, click to the Bextra homepage. For more information on safe use of COX-2 inhibitors and other NSAIDs, please see Understanding COX-2 inhibitor side effects.

Overview

NSAIDs: non-steroidal anti-inflammatory drugs

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

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:

1. Ibuprofen (e.g. brand names such as Advil, Motrin, Nuprin)

2. Naproxen (e.g. brand names such as Aleve, Naprosyn)

3. COX-2 inhibitors (e.g. brand names such as Bextra, Celebrex)

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 persons 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 that 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 and appropriate treatment options.

Please see Understanding COX-2 inhibitor side effects for more information.

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 (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. 

NSAIDs potential risks and complications
NSAIDs are cleared from the blood stream by the kidney, so it is very important that patients over 65 years of age or patients with kidney disease consult a physician prior to taking the medication. If patients take an NSAID for an extended period of time (six months or more), a blood test needs to be performed to check for early signs of kidney damage.

NSAIDs may also cause stomach upset or possibly ulcers. Patients with stomach ulcers or a history of stomach ulcers should first consult with their physician. Signs of stomach ulceration and intestinal bleeding typically include one or a combination of the following symptoms: abdominal pain, black tarry stools, weakness, or dizziness upon standing.

Most types of NSAIDs have a variety of other potential risks and complications associated with them. While most side effects are rare, it is important for patients to remain aware of them and under supervision by a health professional. As a general rule, patients with any of the following factors should be sure to meet with their doctor before taking any type of NSAID:

• Thyroid problems

• Diabetes

• Heart disease

• High blood pressure

• Allergy or reaction to aspirin, other NSAIDs or pain relievers

• Pregnant, about to become pregnant, or breast feeding

• Consume three or more alcoholic beverages a day

• About to have surgery or other invasive procedures (including dental surgery)

In order to ensure that NSAIDs are used safely, patients should meet with a physician to evaluate their individual risk factors (e.g. the patient’s likelihood for developing certain health problems, including heart attack, stroke and gastrointestinal problems) and to determine the most appropriate dosages and treatment options. It is recommended that patients avoid taking over-the-counter NSAIDs for more than 10 days in a row without consulting their physician.

As with all medications, patients should discuss with their doctor medications taken (including herbal remedies, supplements, etc), all other medical conditions and allergies. Patients should strictly follow label directions for all pain medications, including non-prescription medications.  

Other types of NSAIDs
Below is a comprehensive list of different types of NSAIDs.

By: Peter F. Ullrich, Jr., MD
Updated March 2, 2005