10.1.1 NSAIDs


First Choice:
Second Choice:
diclofenac sodium
  • ibuprofen tablets 200mg, 400mg, 600mg; suspension 100mg/5mL: 1.2–2.4g daily in 3–4 divided doses.
  • diclofenac sodium tablets e/c 25mg, 50mg; injection 25mg/mL; suppositories 12.5mg, 25mg, 50mg, 100mg: orally (or rectally), 75–150mg daily in 2–3 divided doses; deep intramuscular injection into gluteal muscle, 75mg 1–2 times daily for max 2 days.
Prescribing Notes
  • NICE guidance for osteoarthritis recommends paracetamol and/or topical NSAIDs may be considered before oral NSAIDS.
  • Patients that require NSAIDs should be prescribed them at the lowest effective dose and long term use should be avoided if possible.
  • Diclofenac is contra-indicated in those with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease or established heart failure. The arterial thrombosis risk with diclofenac is similar to that of the COX-2 inhibitors.
  • Low dose ibuprofen is considered to have the most favourable thrombotic cardiovascular safety profile.
  • For patients with cardiovascular and cerebrovascular disease, current evidence suggests that the risk of heart failure is increased with all NSAIDs. The risk of myocardial infarction is also increased with most NSAIDs, with the possible exception of naproxen. The risk of stroke is increased with most NSAIDs with the possible exception of low dose (<200mg daily) celecoxib.
  • Contra-indications to NSAIDS include proven hypersensitivity to aspirin or any NSAID, severe heart failure, active gastrointestinal bleeding. They should be used with caution in patients with mild-moderate heart failure, renal impairment and history of peptic ulceration.
  • NSAIDs may worsen asthma; they are contra–indicated if aspirin or any other NSAID has precipitated attacks of asthma.
  • Long–term use of high dose ibuprofen may interfere with the cardioprotective effects of low dose aspirin. Naproxen may be a suitable alternative.
  • Patients at high risk of gastrointestinal (GI) adverse effects should be prescribed NSAID + PPI, see LJF 1.3(b). Risk factors for GI adverse effects include previous peptic ulcer, previous GI bleed, alcohol excess, systemic corticosteroids, anticoagulants, SSRIs, age>65 years, high dose NSAIDS.
  • Oral NSAIDs are excluded from the inpatient analgesic strategy for severe or distressing acute musculoskeletal pain in patients aged >65 years. This is due to increased risk of serious GI toxocity and perforation, increased risks of renal impairment and increased cardiovascular risks. Topical NSAIDs may be appropriate, see 10.3
  • Intramuscular or intravenous diclofenac must only be used for up to 2 days due to the risk of tissue necrosis: if necessary, treatment can be continued with tablets or suppositories.

Older patients and other patients at high risk of gastro-intestinal adverse events

Patients at high risk of serious gastro–intestinal adverse events:
First choice:            NSAID (see section 10.1.1) + omeprazole or lansoprazole (see section 1.3)