Clinical Question

How do ibuprofen, ketorolac, and diclofenac compare with one another for the treatment of acute, nonradicular low back pain in adults?

Bottom Line

This study found no differences among ibuprofen, ketorolac, and diclofenac in the primary outcome of overall clinical improvement at five days in adults presenting to the emergency department with acute, nonradicular low back pain. Some of the secondary outcomes favored ketorolac, leaving open the possibility that ketorolac is superior to ibuprofen and diclofenac. (Level of Evidence = 1b−)

Synopsis

Although nonsteroidal anti-inflammatory drugs (NSAIDs) are the recommended first-line treatment for acute low back pain, there is no clear evidence for recommending one oral NSAID over another. The investigators identified adults, 18 to 65 years of age, who presented to an emergency department with acute low back pain. Eligibility criteria included pain between the lower border of the scapulae and the upper gluteal folds without any radicular symptoms that lasted less than two weeks, or a history of direct trauma to the back within the past month. Patients (N = 198) randomly received (concealed allocation assignment) ibuprofen (600 mg every eight hours, as needed), ketorolac (10 mg every eight hours, as needed), or diclofenac (50 mg every eight hours, as needed). Study participants masked to treatment group self-rated overall symptoms, including pain and function, using a validated 24-item low back pain scoring tool. Complete follow-up occurred for 86% of patients at five days.

Using intention-to-treat analysis, no significant group differences occurred in the primary outcome of an improved pain and function score. Several secondary outcomes were assessed, some of which significantly favored ketorolac. The investigators, however, appropriately concluded that the study found no clear evidence to recommend one NSAID over the others.

Study design: Randomized controlled trial (double-blinded)

Funding source: Self-funded or unfunded

Allocation: Concealed

Setting: Emergency department

Reference: Irizarry E, Restivo A, Salama M, et al. A randomized controlled trial of ibuprofen versus ketorolac versus diclofenac for acute, nonradicular low back pain. Acad Emerg Med. 2021;28(11):1228–1235.