Only prescribe an NSAID if the benefits of treatment clearly outweigh the risks and a need for an anti-inflammatory agent is identified.

Prescribing should be based on the safety profile of individual drugs and individual patient risk factors. Use the lowest effective dose for the shortest period of time to control symptoms.

Further information on the prescribing of non-steroidal anti-inflammatory drugs can be found here

NHS England (NHSE) has published new prescribing guidance for various common conditions for which over-the-counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These include mild fever and minor conditions associated with pain such as (but not limited to) headache, coughs and colds, acute sore throat, period pain, mild toothache, mild back pain etc.

Many analgesic containing products to treat these conditions are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

MHRA Drug Safety Update (June 2023): Non-steroidal anti-inflammatory drugs (NSAIDs): potential risks following prolonged use after 20 weeks of pregnancy

• Systemic (oral and injectable) NSAIDs are contraindicated during the last trimester (after 28 weeks) of pregnancy. Prolonged use of NSAIDs from week 20 of pregnancy onwards may be associated with an increased risk of oligohydramnios and constriction of the ductus arteriosus.
• Avoid prescribing systemic NSAIDs from week 20 of pregnancy unless clinically required and prescribe the lowest dose for the shortest time in these circumstances.
• Antenatal monitoring for oligohydramnios should be considered if the mother has been exposed to NSAIDs for several days after week 20 of pregnancy. For further information, see the safety update.
• Refer to the safety update for advice to give to patients.
• COX-2 inhibitors were not included in the latest review. All Coxibs are contraindicated in the third trimester of pregnancy, and some are contraindicated throughout all of pregnancy

Ibuprofen

• Tablets 200mg, 400mg, 600mg (£2.70 = 400mg 3 times daily)
• Oral suspension sugar free 100mg in 5ml (£2.58 = 100ml)
• Gel containing 5% (£2.26 = 100g)

Indications and dose

• Pain and inflammation in rheumatic disease and other musculoskeletal disorders; mild to moderate pain including dysmenorrhoea; postoperative analgesia; dental pain; osteoarthritis.
  • Adult and child over 12 years
    • Oral: Initially 300–400mg 3–4 times daily; increased if necessary to maximum 2.4g daily; maintenance dose of 0.6–1.2g daily may be adequate
    • Topical: Apply up to 3 times a day
• Gout
  • 800mg every 8 hours
• Acute migraine
  • 400–600mg for 1 dose, to be taken as soon as migraine symptoms develop
• Fever with discomfort and pain in children; post-immunisation pyrexia
  • 1–2 months, 5 mg/kg 3–4 times a day. (unlicensed in children under 3 months or body-weight under 5 kg)
  • 3–5 months (body-weight over 5kg), 50mg 3 times daily (maximum 30mg/kg daily)
  • 6-11 months, 50mg 3–4 times daily (maximum 30mg/kg daily)
  • 1–3 years, 100mg 3 times daily (maximum 30mg/kg daily)
  • 4–6 years, 150mg 3 times daily (maximum 30mg/kg daily)
  • 7–9 years, 200mg 3 times daily (up to 30mg/kg daily, maximum 2.4g)
  • 10–11 years, 300mg 3 times daily (up to 30mg/kg daily, maximum 2.4g)
  • 12-17 years, initially 300–400 mg 3–4 times a day; increased if necessary up to 600 mg 4 times a day; maintenance 200–400 mg 3 times a day, may be adequate
• Rheumatic disease in children (including juvenile idiopathic arthritis) (Specialist)
  • 3 months–17 years (body-weight over 5kg), 30–40mg/kg, maximum 2.4g daily in 3–4 divided doses
• Systemic juvenile idiopathic arthritis (Specialist)
  • Up to 60mg/kg, maximum 2.4g daily (unlicensed maximum dose) in 4–6 divided doses

Notes

1. Low dose ibuprofen remains the first line NSAID. If a patient says that they have tried ibuprofen check that the dose taken was 400mg 8 hourly, regularly.
2. MHRA Drug Safety Update (June 2015): High-dose ibuprofen (≥2400mg/day): small increase in cardiovascular risk. When prescribing or dispensing ibuprofen:
   1. Avoid use of high-dose ibuprofen (2400mg or higher per day) in patients with established:
      • ischaemic heart disease
      • peripheral arterial disease
      • cerebrovascular disease
      • congestive heart failure (New York Heart Association [NYHA] classification II-III)
      • uncontrolled hypertension
   2. For further details refer to the MHRA safety update
3. For topical preparations, patients or their carers should be advised against excessive exposure to sunlight of area treated in order to avoid possibility of photosensitivity.

Naproxen

• Tablets 250mg, 500mg (£2.62 = 500mg 12 hourly)

Indications and dose

• Pain and inflammation in musculoskeletal disorders and dysmenorrhoea
  • Adult: 500mg initially, then 250mg every 6–8 hours as required; maximum dose after first day 1.25g daily
  • Child: 5mg/kg twice daily; maximum 1g per day. (Not licensed for use in children under 16 years for musculoskeletal disorders or dysmenorrhoea)
• Acute gout
  • Adult: 750mg initially, then 250mg every 8 hours until attack has passed
  • Child under 16 years not recommended
• Pain and inflammation in rheumatic disease
  • Adult: 0.5–1g daily in 1–2 divided doses
• Juvenile idiopathic arthritis (Specialist)
  • Child 2–17 years: 5–7.5 mg/kg twice daily; maximum 1 g per day. (Not licensed for use in children under 5 years for juvenile idiopathic arthritis)

Notes

1. Naproxen is particularly useful where a sustained effect is required because it has a half-life of 14 hours, to be used in preference to diclofenac sodium sustained release preparations
2. Naproxen e/c tablets offer no extra gastro-protection and are significantly higher in cost and are therefore not included in the formulary

Indometacin

• Capsules 25mg, 50mg (£6.03 = 50mg 8 hourly)

Indications and dose

• Pain and moderate to severe inflammation in rheumatic disease and other musculoskeletal disorders:
  • Oral, 50-200mg daily in divided doses
• Dysmenorrhoea:
  • Oral, up to 75mg daily

Notes

1. Not licensed for use in children. Safety for use in children has not been established.
2. The BNF states: During prolonged oral therapy, ophthalmic and blood examinations are particularly advisable.

Ketoprofen

• Gel containing 2.5% (£2.60 = 50g)

Indications and dose

• Relief of pain in musculoskeletal conditions and osteoarthritis
  • Apply 2-4 times a day for up to 7 days; maximum 15g per day

Notes

1. MHRA Drug Safety Update (Aug 2010, June 2009): Topical ketoprofen: reminder on risk of photosensitivity reactions:
   1. Patients should ensure that treated areas are protected from direct sunlight, ultraviolet (UV) rays, sunlamps, and sunbeds during the whole period of topical ketoprofen treatment and for 2 weeks after stopping; also carefully washing their hands after every application.
   1. Patients should stop treatment immediately if they develop any skin reaction after application of these medicines and seek their doctor's advice
   1. Patients should be informed of the appropriate use of topical ketoprofen as outlined in the product information.

Diclofenac sodium

• Gastro-resistant tablets 25mg, 50mg (£2.82 = 50mg 8 hourly)
• Modified-release capsules 75mg, 100mg (£11.40 = 75mg 12 hourly)
• Suppositories 12.5mg, 25mg, 50mg, 100mg (£2.04 = 50mg x 10 suppositories)
• Injection 75mg in 3ml (£0.99 = 1 ampoule)
• Gel containing 1.16% (£4.63 = 100g)

Indications and dose

• Adult:
  • Pain and inflammation in rheumatic disease and other musculoskeletal disorders, acute gout, osteoarthritis and postoperative pain
    • Oral, 75–150mg daily in 2–3 divided doses
    • Modified-release, 75mg twice daily or 100mg daily
    • Suppositories, 75–150mg daily in divided doses
    • Topical, apply 1.16% gel 3–4 times a day, therapy should be reviewed after 14 days (or after 28 days for osteoarthritis).
    • Deep intramuscular injection into the gluteal muscle, 75mg once daily (twice daily in severe cases) for maximum 2 days
  • Ureteric colic
    • Deep intramuscular injection into the gluteal muscle, 75mg then a further 75mg after 30 minutes if necessary
  • Acute postoperative pain (Hospital Only)
    
    • By intravenous infusion (in hospital setting), 75mg repeated if necessary after 4–6 hours; maximum 150mg in 24 hours for 2 days
  • Prevention of postoperative pain, initially after surgery (Hospital Only)
    
    • By intravenous infusion (in hospital setting), initially after surgery 25–50mg over 15–60 minutes then 5mg/hour; maximum 150mg in 24 hours for 2 days
• Child: 6 months–17 years
  • Pain and inflammation in rheumatic disease including juvenile idiopathic arthritis
    • Oral, 1.5–2.5mg/kg twice daily, total daily dose may alternatively be given in 3 divided doses; maximum 150mg per day. (Not licensed for use in children under 1 year. Solid dose forms containing more than 25mg not licensed for use in children)
  • Postoperative pain (Hospital Only)
  • • By rectum, (Unlicensed under 6 years)
      • Body-weight 8–11kg, 12.5 mg twice daily for maximum 4 days.
      • Body-weight 12kg and above, 1mg/kg 3 times a day (max. per dose 50mg) for maximum 4 days
    • By intravenous infusion (in hospital setting) or deep IM injection (into gluteal muscle), (unlicensed) 0.3–1mg/kg once or twice a day for maximum 2 days, maximum 150 mg per day.

Notes

1. Diclofenac modified-release preparations are considerably more expensive and should be reserved only for patients unable to comply with three times a day dosing for whom naproxen is not effective
2. Diclofenac suppositories may be preferred to diclofenac injection (which may be painful when given IM) for the acute relief of pain e.g. biliary colic
3. Please ensure that the 1.16% strength diclofenac gel is prescribed
4. After topical application, the hands should be washed unless they are the site being treated
5. During use of topical diclofenac, patients should be advised against excessive exposure to sunlight of area treated in order to avoid possibility of photosensitivity
6. To use 75mg/3ml (Voltarol) IV, give as an IV infusion in 100ml NaCl 0.9% or Dextrose 5% buffered with 0.5mL sodium bicarbonate 8.4%
7. Voltarol injection must not be given as an intravenous bolus.
8. Concomitant use of IV diclofenac and anticoagulants (including low molecular weight heparins) is contra-indicated.
9. MHRA Drug Safety Update (June 2013): Diclofenac: new contraindications and warnings:
   1. Diclofenac is now contraindicated in patients with established:
      • ischaemic heart disease
      • peripheral arterial disease
      • cerebrovascular disease
      • congestive heart failure (New York Heart Association [NYHA] classification II–IV)
   2. Patients with these conditions should be switched to an alternative treatment at their next routine appointment
   3. Diclofenac treatment should only be initiated after careful consideration for patients with significant risk factors for cardiovascular events (e.g. hypertension, hyperlipidaemia, diabetes mellitus, and smoking)

Celecoxib

• Capsules 100mg, 200mg (£3.81 = 100mg 12 hourly)

Indications and dose

• Pain and inflammation in osteoarthritis
  • Adult: 200mg daily in 1–2 divided doses, increased if necessary to maximum 200mg twice daily
• Rheumatoid arthritis
  • Adult: 100mg twice daily, increased if necessary to 200mg twice daily
• Ankylosing spondylitis
  • Adult: 200mg daily in 1–2 divided doses, increased if necessary to maximum 400mg daily in 1–2 divided doses

Notes

1. Only to be used if inadequate response to NSAIDs, if NSAIDs are not suitable on the basis of patient risk factors (e.g. patient at a particularly high risk of developing gastrointestinal ulceration or bleeding), or PPIs are contra-indicated or not tolerated
2. Discontinue if no improvement after 2 weeks on maximum dose
3. BNF recommends monitor blood pressure before and during treatment

Etoricoxib

• Tablets 30mg, 60mg, 90mg, 120mg (£2.24 = 90mg daily)

Indications and dose

• Pain and inflammation in osteoarthritis
  • Adult: 30mg once daily, increased if necessary to 60mg once daily
• Rheumatoid arthritis, and ankylosing spondylitis
  • Adult: 60mg once daily, increased if necessary to 90mg once daily. Once the patient is clinically stabilised, down-titration to 60mg once daily may be appropriate.
• Acute gout
  • Adult: 120mg once daily for maximum 8 days

Notes

1. Only to be used if inadequate response to NSAIDs, if NSAIDs are not suitable on the basis of patient risk factors (e.g. patient at a particularly high risk of developing gastrointestinal ulceration or bleeding), or PPIs are contra-indicated or not tolerated
2. The cardiovascular and other important risks of etoricoxib may increase with dose and duration of exposure. Therefore, the lowest effective daily dose should be used, and the need for treatment should be regularly reassessed.
3. In the absence of therapeutic benefit, other treatment options should be considered
4. MHRA Drug Safety Update (July 2008): Etoricoxib: prescribing to patients with high blood pressure
   1. Patients whose blood pressure is persistently above 140/90 mmHg and inadequately controlled must not receive Etoricoxib.
   2. High blood pressure should be controlled before starting treatment and should be monitored for 2 weeks after the start of treatment and regularly thereafter.
   3. Monitor patients closely for any signs and symptoms of cardiovascular side-effects (eg, fluid retention, high blood pressure, shortness of breath, or chest pain)