Note: topical NSAIDs are first line for Osteoarthritis
Prescribing Notes
- In osteoarthritis first choice pharmacological management is a topical NSAID (formulary choice – ibuprofen 5% gel) with oral preparations second line if topical treatment is ineffective or not suitable, see 10.3.2 and NICE NG226.
- All NSAIDs should generally be used at the lowest effective dose and for the shortest period of time necessary to control symptoms.
- Differences in anti-inflammatory activity between NSAIDs are small, but there is considerable variation in individual response and tolerance. About 60% of patients will respond to any NSAID; of the others those who do not respond to one may well respond to another. See BNF NSAID treatment summary.
- Low-dose ibuprofen (≤1200mg per day) is an appropriate first choice oral NSAID in view of its low risk of GI and CV side effects. Naproxen is also included as a first choice as it may have a lower CV risk than some other NSAIDs.
- When considering a choice for patients at risk of CV complications, diclofenac, etoricoxib and high dose ibuprofen (>2400mg/day) should be avoided.
- Ibuprofen: People taking >2400mg of ibuprofen per day are at higher risk of arterial thrombotic events. No increased risk is seen at doses of up to 1200mg per day. Due to limited data, it is uncertain whether doses between 1200mg and 2400mg are associated with an increased risk
- If a COX-2 inhibitor is required, celecoxib 100mg twice daily may be considered when the benefits are expected to outweigh the risks, there are insufficient CV safety data for higher doses
- Assess GI risk factors and consider need for gastroprotection– refer to CKS and PrescQIPP. Refer to box below for proton pump inhibitor (PPI) dose for gastroprotection.
| PPI dose for gastroprotection in those who require continued NSAID treatment* | |
| NI Formulary Choices | Dose |
| Lansoprazole 15mg, 30mg capsules | 15-30mg once daily |
| Omeprazole 20mg capsules | 20mg once daily |
| *Prescription directions to include the instruction “while taking [name NSAID]” | |
- Ibuprofen may interfere with the cardioprotective effects of low dose aspirin when taken concomitantly. Ibuprofen should be taken at least 30 minutes after aspirin ingestion, or at least 8 hours before aspirin ingestion to avoid any potential interaction. Risk may be greater in those taking regular, rather than intermittent, ibuprofen and regular co-prescription should generally be discouraged.
Side Effects
- All NSAIDs carry the risk of side effects which can be serious and life-threatening. Although the risk varies between individual NSAIDs, important side effects include:
- GI (e.g. perforation, ulcer, bleeding)
- Renal (e.g. deterioration of renal function, renal failure)
- CV (e.g. stroke, myocardial infarction) see MHRA
Cautions
- Cautions and contraindications vary between drugs, refer to BNF and/or product literature for full information.
- During an acute illness, consider temporarily stopping NSAID in order to reduce the risk of acute kidney injury. See ‘sick day rules’.
- NSAIDs should be used with caution in the elderly (risk of serious side-effects and fatalities).
- NSAIDs may worsen asthma in patients who are susceptible; they are contraindicated if aspirin or any other NSAID has precipitated attacks of asthma.
- NSAIDs: potential risks following prolonged use after 20 weeks of pregnancy – see MHRA
- Avoid use of NSAIDs with severe hypertension, i.e. systolic blood pressure consistently above 170mmHg and / or diastolic blood pressure consistently above 100mgHg
- Etoricoxib may be associated with severe effects on blood pressure and is therefore contraindicated in patients with BP persistently >140/90mmHg. Hypertension should be controlled before treatment with etoricoxib is started and BP should be monitored within two weeks after initiation, after six weeks and periodically thereafter – see MHRA.
- Etoricoxib: lower recommended dose of 60mg daily for patients with rheumatoid arthritis or ankylosing spondylitis – see MHRA