What are the commonly recommended Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and their doses used in Indian General Practice (GP) Outpatient Department (OPD) settings for beginners?

NSAIDs for Indian General Practice: Dosages and Brand Names

For beginners in Indian general practice settings, ibuprofen 400-600 mg orally every 4-6 hours is the recommended first-line NSAID for most pain conditions. 1

First-Line NSAIDs for Indian GP Settings

Ibuprofen

• Dosage: 400-600 mg orally every 4-6 hours
• Maximum daily dose: 2400 mg
• Common Indian brands: Brufen, Ibugesic, Combiflam (with paracetamol)
• Indications: Musculoskeletal pain, headache, dental pain
• Advantages: Better safety profile than most NSAIDs, available OTC 2

Naproxen

• Dosage: 250-500 mg twice daily
• Maximum daily dose: 1500 mg
• Common Indian brands: Naprosyn, Naprex, Xenobid
• Indications: Osteoarthritis, rheumatoid arthritis, longer-lasting pain relief 1
• Advantages: Twice-daily dosing improves compliance

Diclofenac

• Dosage: 50 mg three times daily or 75 mg twice daily
• Maximum daily dose: 150 mg
• Common Indian brands: Voveran, Diclonac, Voltaren
• Indications: Acute pain conditions, post-operative pain 3

Second-Line NSAIDs

Aceclofenac

• Dosage: 100 mg twice daily
• Common Indian brands: Aceclo, Zerodol, Hifenac
• Indications: Osteoarthritis, rheumatoid arthritis

Etodolac

• Dosage: 200-400 mg every 6-8 hours for acute pain; 300 mg 2-3 times daily for arthritis
• Maximum daily dose: 1000 mg for acute pain
• Common Indian brands: Etova, Etogesic
• Indications: Osteoarthritis, rheumatoid arthritis 4

Nimesulide (Note: Restricted use in many countries)

• Dosage: 100 mg twice daily
• Common Indian brands: Nimulid, Nise
• Indications: Short-term pain relief only

Algorithm for NSAID Selection in Indian GP Setting

1. For mild pain:

   • Start with paracetamol 500-1000 mg every 6 hours
   • If insufficient, add or switch to ibuprofen 400 mg every 6 hours 5

2. For moderate pain:

   • Ibuprofen 400-600 mg every 6 hours OR
   • Naproxen 500 mg twice daily 1

3. For severe pain:

   • Diclofenac 50 mg three times daily OR
   • Consider combination therapy (NSAID + paracetamol) 1

4. For chronic conditions (e.g., osteoarthritis):

   • Naproxen 500 mg twice daily OR
   • Etodolac 300 mg twice daily 1

Important Precautions

High-Risk Patients

• Elderly (>60 years): Use lower doses, prefer ibuprofen or naproxen
• History of peptic ulcer: Add proton pump inhibitor (e.g., omeprazole 20 mg daily)
• Renal impairment: Avoid NSAIDs if possible, or use lowest effective dose for shortest duration
• Cardiovascular disease: Avoid NSAIDs if possible; if necessary, naproxen may have better CV profile 1

Monitoring

• Baseline blood pressure, renal function, and liver function tests
• Repeat every 3 months for long-term use
• Watch for GI symptoms, edema, or worsening hypertension 1

Common Pitfalls to Avoid

1. Prolonged use without gastroprotection: Always consider adding a PPI for patients on long-term NSAID therapy or those >60 years old

2. Inappropriate use in asthma patients: Avoid aspirin and ibuprofen in patients with aspirin-sensitive asthma 3

3. Multiple NSAID prescriptions: Never prescribe two different NSAIDs simultaneously as this increases toxicity without additional benefit 1

4. Fixed-dose combinations (FDCs): While popular in India (prescribed by up to 76% of orthopedic surgeons), use with caution as they may not provide optimal dosing for individual components 3

5. Ignoring renal function: NSAIDs can cause acute kidney injury, especially in dehydrated patients or those with pre-existing renal disease 1

Remember that NSAIDs should be used at the lowest effective dose for the shortest duration possible to minimize adverse effects 1, 4. For chronic pain conditions, consider periodic drug holidays or rotation between different NSAIDs if long-term therapy is necessary.