With NSAIDs, pick the one that works best, and stick with it
DEAR DR. ROACH: I’m a 79-year-old man in generally good health. What is not under control is the lower back pain I have been suffering due to disk deterioration. I have been able to control it with physical therapy, stretching exercises, chiropractic and occasional NSAID medication. As I’m getting older, the pain is getting worse, and I have to rely on pain medication, consisting of ibuprofen 800 mg, meloxicam 7.5 mg, salsalate 750 mg and naproxen.
I am well aware of the side effects, and I would like your professional opinion about the safest one of these to take now that it seems I need them more often. — L.T. ANSWER: My first point of advice is that you should absolutely not mix these medications. You should pick one and stick with it. Using multiple types of nonsteroidal anti-inflammatory drugs leads to higher toxicity without additional benefit.
My second point is that there is no “safest” NSAID. It depends on the dose and the type of adverse event you are worried about. For example, there is weak-to-moderate evidence that naproxen is safer than others specifically in the risk for heart disease. Salsalate has less effect on platelets (blood clotting cells) and therefore a lower risk of gastrointestinal bleeding. Ibuprofen has a very low rate of overall gastrointestinal effects at most doses: 800 mg is the maximum dose and carries a higher risk than 400 or 600 mg, but of course the total daily dose is important too. These drugs all have different therapeutic effects on different people. One person might have such good pain relief with meloxicam 7.5 mg daily — better than what they have with ibuprofen 800 mg three times daily — that this drug might be safest for him or her, even if in studies it has a slightly higher rate of gastrointestinal bleeding than ibuprofen when used at a higher dose. *** Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGood-Health@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
