What medications can help with pain and inflammation?

Medications for Pain and Inflammation Management

NSAIDs are recommended as first-line drug treatment for patients with pain and inflammation, with acetaminophen as an alternative for those who cannot tolerate NSAIDs or have contraindications to them. 1

First-Line Treatment: NSAIDs

NSAID Selection and Dosing

• Ibuprofen is the safest NSAID and should be used first at 1.2g daily 1, 2
• If inadequate relief, increase ibuprofen to 2.4g daily 1
• Alternative NSAIDs if ibuprofen ineffective:
  • Naproxen: 500mg twice daily
  • Diclofenac: 50mg 2-3 times daily
  • Celecoxib: 200mg daily (preferred in patients with high GI risk)

NSAID Safety Considerations

• NSAIDs carry risks of:
  • Gastrointestinal complications (5.36 times higher risk of serious GI events) 1
  • Cardiovascular events (especially with higher doses and longer duration) 3
  • Renal impairment
  • Hypertension

Gastroprotection with NSAIDs

• Add a PPI (proton pump inhibitor) for patients with risk factors 2:

  • Age ≥60 years
  • History of peptic ulcer disease
  • Concurrent use of anticoagulants or corticosteroids
  • High-dose or multiple NSAIDs

• PPIs reduce NSAID-related ulcers by up to 90% and are more effective than H2-receptor antagonists 2

Alternative/Second-Line Options

Acetaminophen (Paracetamol)

• Recommended when NSAIDs are contraindicated, poorly tolerated, or insufficient 1
• Dosing: Up to 4g daily (1g four times daily) 1
• Less effective than NSAIDs for inflammatory pain 4, 5
• Safety concerns with long-term use or doses >3g daily in patients with liver disease or alcohol use 1

Opioid Analgesics

• Consider only when NSAIDs and acetaminophen are insufficient, contraindicated, or poorly tolerated 1
• Should be used cautiously due to risk of dependence and side effects
• Examples: codeine, tramadol (weaker opioids preferred initially)

Topical Treatments

• Topical NSAIDs (e.g., diclofenac gel) can be effective for localized pain with fewer systemic side effects 1
• Capsaicin cream may provide additional relief for localized pain

Special Considerations

Inflammatory Arthritis

• NSAIDs are particularly effective for inflammatory conditions like rheumatoid arthritis and ankylosing spondylitis 1
• For ankylosing spondylitis, continuous NSAID use is preferred if symptomatic 1
• Consider disease-modifying agents (DMARDs) for persistent inflammatory arthritis

Osteoarthritis

• NSAIDs are more effective than acetaminophen for moderate-to-severe osteoarthritis pain 4, 5
• For mild OA pain, acetaminophen may be tried first due to better safety profile 1

Elderly Patients

• Use lower doses of NSAIDs
• Consider shorter duration of therapy
• More vigilant monitoring for adverse effects
• PPI gastroprotection strongly recommended 2

Monitoring Recommendations

• Regular assessment of pain relief and function
• Monitor for GI symptoms (abdominal pain, dyspepsia, melena)
• Periodic blood pressure checks
• Renal function tests for those on long-term NSAIDs
• Consider fecal occult blood testing for high-risk patients 2

Treatment Algorithm

1. Start with ibuprofen 1.2g daily (lowest effective dose)
2. If insufficient relief after 1-2 weeks, increase to 2.4g daily
3. If still inadequate or not tolerated, switch to alternative NSAID
4. Add PPI for gastroprotection in high-risk patients
5. If NSAIDs contraindicated or ineffective, use acetaminophen up to 4g daily
6. Consider opioid analgesics only when other options fail

Remember that the shortest duration of NSAID therapy at the lowest effective dose should be used to minimize risks while controlling pain and inflammation.