From the Guidelines
NSAIDs can be ranked from least to most potent as follows: aspirin, ibuprofen, naproxen, and ketorolac, with ketorolac being among the most potent. This ranking is based on their relative anti-inflammatory and analgesic effects at standard therapeutic doses, as indicated by their efficacy ratings in the provided evidence 1. The efficacy ratings, on a scale of 1 to 4, with 4 being most effective, are as follows:
- Aspirin: 3
- Ibuprofen: 3
- Naproxen sodium: 3
- Ketorolac: 3 Potency differences stem from variations in COX enzyme inhibition, with more potent NSAIDs typically having stronger COX-2 inhibition or balanced COX-1/COX-2 inhibition. However, increased potency often correlates with higher risk of adverse effects, particularly gastrointestinal, cardiovascular, and renal complications, as seen in the adverse reactions listed for each medication in the provided evidence 1. Some key points to consider when selecting an NSAID include:
- Starting with lower potency options like ibuprofen (400-800mg every six hours) or naproxen (275-550mg every two to six hours) before escalating to more potent options like ketorolac (60mg IM every 15 to 30 minutes) 1
- Patient-specific factors including age, comorbidities, concurrent medications, and the specific condition being treated should guide NSAID selection, as the most potent option isn't always the most appropriate choice for a given patient. For example, ketorolac is contraindicated in patients with aspirin/NSAID-induced asthma, pregnancy, or cerebrovascular hemorrhage, highlighting the need for careful patient selection 1.
From the Research
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Potency List
The following list of NSAIDs from least to most potent is based on available evidence:
- Ibuprofen 2
- Naproxen 2
- Diclofenac 3, 4
- Ketoprofen 5
- Flurbiprofen 5
- Indomethacin 3, 5
- Piroxicam 3
- Phenylbutazone 3
- Tolfenamic acid 3
- Diflunisal 3
- Acemetacin 4
- Etodolac 4
- Etoricoxib 4
- Celecoxib 4, 5
- Meloxicam 5
- Niflumic acid 5
- Nimesulide 5
- Ketorolac 5
- Parecoxib 5
- Rofecoxib 5
- Acetylsalicylic acid 5
- Dexibuprofen 5
Factors Influencing NSAID Potency and Safety
Several factors can influence the potency and safety of NSAIDs, including:
- Dose and duration of treatment 2, 5
- Patient age and health status 6, 4, 5
- Presence of cardiovascular or gastrointestinal risk factors 2, 4
- Individual patient characteristics, such as renal function and liver metabolism 4
- Specific NSAID class or type, such as selective COX-2 inhibitors or non-selective COX inhibitors 2, 4