Lit Matters 1: Diclofenac vs. Ibuprofen for back pain

Acute, nontraumatic, non-radicular low back pain improves with NSAIDs, but route matters. In a randomized ED trial, oral ibuprofen produced better short-term functional recovery than topical diclofenac, while combination therapy added no clear benefit.

NSAID Route for Acute Back Pain

• ED low back phenotype: The study focused on acute, nontraumatic, non-radicular musculoskeletal low back pain in discharged ED patients, a narrower phenotype than the all-comers back pain population seen on shift.
• Functional outcome signal: Roland-Morris disability scores improved in all groups by 2 days, but oral ibuprofen showed the largest gain, with about a 10-point improvement from baseline.
• Topical diclofenac performance: Diclofenac 1% gel was active but less effective than systemic NSAID therapy, and patients using gel alone were more likely to report moderate to severe pain during follow-up.
• No combination advantage: Adding diclofenac gel to ibuprofen did not produce a meaningful bump over ibuprofen alone, a useful reminder that more NSAID route stacking is not automatically better.
• When topical still matters: Topical diclofenac remains a reasonable option when oral NSAIDs are contraindicated, but the substitution question is less settled because the trial had no true placebo arm. We get into that bedside nuance in the episode.
• Applicability caveats: The primary endpoint used the Roland-Morris Disability Questionnaire, and both the ED validation of that tool and the chosen clinically important difference are worth keeping in mind when applying the result.