10.1.1 Non-steroidal anti-inflammatory drugs

General guidance

• In single doses NSAIDs have analgesic activity comparable to that of paracetamol. In regular full dosage NSAIDs have both a lasting analgesic and an anti-inflammatory effect which makes them useful in the treatment of continuous or regular pain associated with inflammation.
• Many patients with degenerative joint disease can have satisfactory relief of symptoms by using paracetamol alone. However, those with inflammatory disease of the spine, e.g. ankylosing spondylitis or a spondylo-arthropathy, almost invariably require therapy with a NSAID.
• The main difference between NSAIDs is in the incidence and type of side-effects. Before treatment is started the prescriber should weigh efficacy against possible side-effects.
• NICE guidance advises that COX II selective agents should be used in preference to standard NSAIDs in patients who may be at “high risk” of developing serious gastrointestinal adverse effects. Patients at “high risk” of developing serious gastrointestinal adverse events include those of 65 years of age and over, those using concomitant medication known to increase the likelihood of upper gastrointestinal events (e.g. steroids, anticoagulants), those with serious co-morbidity (e.g. cardiovascular disease, renal or hepatic impairment, diabetes and hypertension) or those requiring the prolonged use of maximum recommended doses of standard NSAIDs. The risk of NSAID-induced complications is particularly increased in patients with a previous clinical history of gastroduodenal ulceration, bleeding or perforation. The use of even a Cox II selective agent should therefore be considered carefully in this situation.

Recommended drugs

Ibuprofen (use doses up to 1600mg – 2400mg daily before using another NSAID)

Naproxen

Cox II selective agent

Celecoxib

Meloxicam

Other agents usually on the recommendation of a rheumatologist

Tiaprofenic Acid

Azapropazone