What is the ranking of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in order of strength?

NSAIDs Ranked by Strength

Oral NSAIDs can be ranked by their relative analgesic potency, with diclofenac and indomethacin being the strongest, followed by meloxicam, naproxen, ibuprofen, and aspirin in descending order of strength.

Ranking of NSAIDs by Analgesic Potency

NSAIDs vary in their analgesic potency, anti-inflammatory effects, and side effect profiles. Here is the ranking from strongest to weakest:

Strongest NSAIDs

1. Diclofenac - Highest potency for pain relief and inflammation
2. Indomethacin - Very strong anti-inflammatory effects

Moderate Strength NSAIDs

1. Meloxicam - Strong with COX-2 selectivity
2. Naproxen - Good balance of efficacy and safety
3. Ketoprofen - Effective but higher GI risk

Lower Strength NSAIDs

1. Ibuprofen - Moderate strength, better safety profile
2. Aspirin - Lowest analgesic potency among common NSAIDs

Factors Affecting NSAID Selection

The selection of an appropriate NSAID should be based on several factors beyond just strength:

• Gastrointestinal (GI) Risk: Patients with increased GI risk should use non-selective NSAIDs with a gastroprotective agent or a COX-2 selective inhibitor 1
• Cardiovascular Risk: COX-2 inhibitors are contraindicated in patients with elevated cardiovascular risk 1
• Age: Patients ≥65 years have higher risk of adverse effects 1
• Concomitant Medications: Especially aspirin, steroids, or anticoagulants 1

NSAID Safety Considerations

Gastrointestinal Safety

• Ibuprofen has the lowest GI risk among traditional NSAIDs
• Diclofenac and indomethacin have higher GI toxicity
• COX-2 selective NSAIDs (meloxicam, celecoxib) have reduced GI risk

Cardiovascular Safety

• Naproxen has the most favorable cardiovascular profile
• COX-2 selective inhibitors have increased cardiovascular risk
• All NSAIDs should be used with caution in patients with cardiovascular disease 1

Clinical Application

For patients requiring chronic NSAID therapy, the American College of Chest Physicians recommends:

• First-line for mild pain: Lower strength NSAIDs like ibuprofen or naproxen 1
• For moderate to severe pain: Consider stronger NSAIDs like diclofenac or indomethacin 1
• For patients with GI risk factors: Use NSAIDs with a proton pump inhibitor or consider COX-2 selective agents 1

Common Pitfalls to Avoid

• Inadequate dosing: Using insufficient doses before declaring treatment failure
• Prolonged use of high-strength NSAIDs: Increases risk of adverse effects
• Failure to consider patient-specific factors: Age, comorbidities, and concomitant medications significantly impact NSAID selection
• Using multiple NSAIDs simultaneously: Increases risk without additional benefit

Remember that NSAIDs should be used at the lowest effective dose for the shortest duration possible to minimize adverse effects while providing adequate pain relief 2.