10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)

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.

Ibuprofen
  • Tablets 200mg, 400mg, 600mg (£2.87 = 400mg 3 times daily)
  • SuspensionSF 100mg/5ml (£1.13 = 100ml)
  • Gel containing 5% (£4.62 = 100g)

Indications

  • Pain and inflammation in rheumatic disease (including juvenile idiopathic arthritis) and other musculoskeletal disorders;
  • Mild to moderate pain including dysmenorrhoea; postoperative analgesia; migraine; dental pain; fever with discomfort and pain in children; post-immunisation pyrexia

Dose

  • Adult and child over 12 years, 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
  • Pain and fever in children
    • 1–3 months, see BNF for Children
    • 3–6 months (body-weight over 5kg), 50mg 3 times daily (maximum 30mg/kg daily)
    • 6 months–1 year, 50mg 3–4 times daily (maximum 30mg/kg daily)
    • 1–4 years, 100mg 3 times daily (maximum 30mg/kg daily)
    • 4–7 years, 150mg 3 times daily (maximum 30mg/kg daily)
    • 7–10 years, 200mg 3 times daily (up to 30mg/kg daily, maximum 2.4g)
    • 10–12 years, 300mg 3 times daily (up to 30mg/kg daily, maximum 2.4g)
  • Rheumatic disease in children (including juvenile idiopathic arthritis)
    • 3 months–18 years (body-weight over 5kg), 30–40mg/kg, maximum 2.4g daily in 3–4 divided doses
    • in systemic juvenile idiopathic arthritis up to 60mg/kg, maximum 2.4g daily (unlicensed) in 4–6 divided doses
  • Osteoarthritis

Notes

  1. MHRA Drug Safety Alerts (June 2015): When prescribing or dispensing ibuprofen:
    1. avoid use of high-dose ibuprofen (2400mg or higher per day) in patients with established:
      1. ischaemic heart disease
      2. peripheral arterial disease
      3. cerebrovascular disease
      4. congestive heart failure (New York Heart Association [NYHA] classification II-III)
      5. uncontrolled hypertension
Indometacin
  • Capsules 25mg, 50mg (£3.39 = 50mg 8 hourly)

Indications

  • Acute gout

Dose

  • 150-200mg daily in divided doses
Naproxen
  • Tablets 250mg, 500mg (£2.30 = 500mg 12 hourly)

Indications

  • Pain and inflammation in rheumatic disease (including juvenile idiopathic arthritis) and other musculoskeletal disorders
  • Dysmenorrhoea
  • Acute gout

Dose

  • Rheumatic disease, 0.5–1g daily in 1–2 divided doses; child 2–18 years, juvenile idiopathic arthritis, see BNF for Children
  • Acute musculoskeletal disorders and dysmenorrhoea, 500mg initially, then 250mg every 6–8 hours as required; maximum dose after first day 1.25g daily; child under 18 years, see BNF for Children
  • Acute gout, 750mg initially, then 250mg every 8 hours until attack has passed

Notes

  1. Naproxen has a longer half-life than diclofenac and ibuprofen and its use may avoid the need for a slow release preparation.
Ketoprofen
  • Gel containing 2.5% (£2.98 = 100g)

Indications

Dose

  • Apply 2-4 times a day for up to 7 days

Notes

  1. MHRA Drug Safety Update (Aug 2010) Patients should ensure that treated areas are protected from sunlight during the whole period of topical ketoprofen treatment and for 2 weeks after stopping treatment; they should also carefully wash their hands after every application. Patients should stop treatment immediately if they develop any skin reaction after application of these medicines and seek their doctor's advice. Patients should be informed of the appropriate use of topical ketoprofen as outlined in the product information.
Diclofenac
  • Tablets 25mg, 50mg (£7.74 = 50mg 8 hourly)
  • Sustained release caps 75mg, 100mg (£9.69 = 75mg 12 hourly)
  • Dispersible tablets 50mg (£29.72 = 50mg 8 hourly)
  • Suppositories 12.5mg, 25mg, 50mg, 100mg (£2.04 = 50mg x 10)
  • Injection 75mg in 3ml (£0.99 = 1 ampoule)
  • Injection (iv/im) 75mg/2ml (Dyloject®)
  • Gel containing 1.16% (£5.63 = 100g)

Indications

  • Pain and inflammation in rheumatic disease (including juvenile idiopathic arthritis) and other musculoskeletal disorders
  • Acute gout
  • Postoperative pain
  • Osteoarthritis

Dose

  • Oral, 75–150mg daily in 2–3 divided doses
  • Sustained release, 75mg twice daily, 100mg daily
  • Suppositories, 75–150mg daily in divided doses
  • Juvenile idiopathic arthritis, child 6 months–18 years, by mouth, see BNF for Children
  • Postoperative pain, child 6 months–18 years, by rectum, see BNF for Children
  • Deep intramuscular injection into the gluteal muscle
    • acute exacerbations of pain and postoperative pain, 75mg once daily (twice daily in severe cases) for maximum 2 days; child 2–18 years, see BNF for Children
    • ureteric colic, 75mg then a further 75mg after 30 minutes if necessary
  • By intravenous infusion (in hospital setting)
    • acute postoperative pain, 75mg repeated if necessary after 4–6 hours; maximum 150mg in 24 hours for 2 days; child 2–18 years, see BNF for Children
    • Prevention of postoperative pain, initially after surgery 25–50mg over 15–60 minutes then 5mg/hour; maximum 150mg in 24 hours for 2 days

Notes

  1. To use 75mg/3ml (Voltarol®) IV use, give as an IV infusion in 100ml NaCl 0.9% or Dextrose 5% buffered with 0.5mL sodium bicarbonate 8.4%
  2. Voltarol® injection must not be given as an intravenous bolus.
  3. Consider renal function when prescribing any NSAID. Avoid NSAIDs in severe renal impairment. This is of particular relevance to Dyloject® which has an excipient which is excreted renally and may accumulate in patients with renal impairment.
  4. Concomitant use of IV diclofenac and anticoagulants (including low molecular weight heparins) is contra-indicated.
  5. Please ensure that the correct 1% diclofenac gel is prescribed.

The COX-ll inhibitors, celecoxib and etoricoxib, are formulary drugs only when used for the licensed indications and conditions listed below.

Celecoxib
  • Capsules 100mg, 200mg (£1.81 = 100mg 12 hourly)

Indications

  • Pain and inflammation in osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis. If inadequate response to NSAIDs or NSAIDs not suitable on basis of patient risk factors (e.g. patient at a particularly high risk of developing gastrointestinal ulceration or bleeding).
  • Contra-indication or intolerance to PPI.

Dose

  • Osteoarthritis, 200mg daily in 1–2 divided doses, increased if necessary to maximum 200mg twice daily
  • Rheumatoid arthritis, 100mg twice daily, increased if necessary to 200mg twice daily
  • Ankylosing spondylitis, 200mg daily in 1–2 divided doses, increased if necessary to maximum 400mg daily in 1–2 divided doses
Etoricoxib
  • Tablets 30mg, 60mg, 90mg, 120mg (£22.96 = 90mg daily)

Indications

  • Pain and inflammation in osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis. If inadequate response to NSAIDs or NSAIDs not suitable on basis of patient risk factors (e.g. patient at a particularly high risk of developing gastrointestinal ulceration or bleeding).
  • Contra-indication or intolerance to PPI.
  • Acute gout

Dose

  • Osteoarthritis, adult and child over 16 years, 30mg once daily, increased if necessary to 60mg once daily (maximum)
  • Rheumatoid arthritis and ankylosing spondylitis, adult and child over 16 years, 60mg once daily, increased if necessary to 90mg once daily (maximum). Once the patient is clinically stabilised, down-titration to 60mg once daily may be appropriate.
  • Acute gout, adult and child over 16 years, 120mg once daily (maximum) for maximum 8 days

Notes

  1. MHRA Drug Safety Update (July 2008): Patients whose blood pressure is persistently above 140/90 mm Hg and inadequately controlled must not receive Etoricoxib. Furthermore, high blood pressure should be controlled before starting treatment, and should be monitored for 2 weeks after the start of treatment and regularly thereafter.
  2. The cardiovascular and other important risks of etoricoxib (Arcoxia) 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.

 

Home > Formulary > Chapters > 10. Musculoskeletal & joint diseases > 10.1 Drugs used in rheumatic diseases and gout > 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)

 

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