Guidelines for NSAID Use in Pain Management
NSAIDs should be prescribed based on patient risk factors, with appropriate gastroprotective measures for high-risk patients and complete avoidance in those with very high risk of complications. 1
Patient Risk Stratification for NSAID Use
Low-Risk Patients
- NSAIDs alone are appropriate for patients <65 years with no previous gastrointestinal events and not on aspirin 2
- Use the lowest effective dose for the shortest possible duration 1, 3
- Acetaminophen (1g every 4-6 hours, max 4g/day) is recommended as first-line treatment for mild to moderate pain 2
Moderate-Risk Patients (One Risk Factor)
- For patients >65 years without other risk factors: Consider either an NSAID or COX-2 inhibitor alone (rated as "uncertain" appropriateness) 2
- For patients with previous GI events OR on aspirin: Either a COX-2 inhibitor alone OR an NSAID plus PPI is appropriate 2, 1
High-Risk Patients (Multiple Risk Factors)
- For patients with previous GI events AND on aspirin: Use either an NSAID or COX-2 inhibitor WITH a PPI 2, 1
- For patients with cardiovascular risk: Naproxen has the most favorable cardiovascular profile 1
- For patients with GI risk but low CV risk: Celecoxib (100-200mg daily) with PPI is preferred 1
Very High-Risk Patients
- Complete avoidance of NSAIDs is recommended for patients with:
Specific Pain Conditions and NSAID Recommendations
- Low back pain: NSAIDs or skeletal muscle relaxants are recommended as first-line therapy 2
- Musculoskeletal injuries: Topical NSAIDs with/without menthol gel as first-line, oral NSAIDs as second-line 2
- Dental pain: NSAIDs are recommended as first-line treatment 2
- Kidney stone pain: NSAIDs are at least as effective as opioids and can decrease ureteral spasm 2
- Migraine: NSAIDs, triptans, or their combinations with antiemetics as needed 2
- Inflammatory pain (especially bone pain): NSAIDs are particularly effective 2
Gastroprotection Strategies
- Proton Pump Inhibitors (PPIs): Standard dose (e.g., omeprazole 20mg daily) is sufficient for gastroprotection 1
- H. pylori testing: Consider testing and treating in patients with history of ulcer or ulcer complications 1
- Duration of gastroprotection: PPI therapy should continue for the entire duration of NSAID treatment 1
- Misoprostol: Alternative to PPIs but side effects may limit adherence 1
- H2-receptor antagonists: Not recommended as they don't prevent gastric ulcers 1
Important Contraindications and Precautions
- NSAIDs should not be used with methotrexate 2
- Use caution with nephrotoxic (particularly cisplatin) or myelotoxic chemotherapy 2
- NSAIDs may increase the risk of heart attack or stroke, especially with longer use in people with heart disease 3
- Never use NSAIDs immediately before or after coronary artery bypass graft surgery 3
- Risk of GI bleeding increases with:
- Concomitant corticosteroids or anticoagulants
- Longer duration of use
- Smoking
- Alcohol consumption
- Older age
- Poor health 3
Monitoring Recommendations
- Measure blood pressure before starting treatment 1, 4
- Screen for unrecognized chronic kidney disease in high-risk cases 4
- Investigate unexplained iron-deficiency anemia 4
- Monitor blood pressure and renal function after initiating therapy 1, 4
- Watch for signs of GI bleeding (vomiting blood, black/tarry stools) 3
Common Pitfalls to Avoid
- Using two products of the same pharmacological class with the same kinetics (e.g., two sustained-release opioids) 2
- Assuming enteric-coated aspirin significantly reduces GI bleeding risk 1
- Failing to provide gastroprotection for high-risk patients 2, 1
- Overlooking cardiovascular risks when selecting NSAIDs for patients with heart disease 1, 3
- Continuing NSAIDs longer than necessary, increasing risk of adverse events 3
By following these evidence-based guidelines, clinicians can optimize the benefits of NSAIDs while minimizing the risks of serious complications.