What is the recommended dosing for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

NSAID Dosing Recommendations

For acute pain management in the emergency department, ibuprofen 400-600 mg orally every 4-6 hours is the recommended first-line NSAID, with alternative NSAIDs such as naproxen or celecoxib if ibuprofen is unavailable. 1

Standard Dosing by Indication

Acute Pain (Emergency Department Setting)

• Ibuprofen: 400-600 mg orally every 4-6 hours 1
• Naproxen: Alternative NSAID if ibuprofen unavailable 1
• Ketorolac: 60 mg IM every 15-30 minutes, maximum 120 mg/day, not to exceed 5 days 1

Acute Pericarditis

• Aspirin: 750-1000 mg every 8 hours for 1-2 weeks, then taper by 250-500 mg every 1-2 weeks 1
• Ibuprofen: 600 mg every 8 hours for 1-2 weeks, then taper by 200-400 mg every 1-2 weeks 1
• Treatment duration is symptom and CRP-guided, generally 1-2 weeks for uncomplicated cases 1

Degenerative Arthritis (Chronic Pain)

• Initial therapy: Paracetamol up to 4 g daily 1
• If paracetamol fails: Ibuprofen 1.2 g daily 1
• If inadequate relief: Increase ibuprofen to 2.4 g daily, or add paracetamol up to 4 g daily 1
• Alternative NSAIDs: Diclofenac or naproxen if ibuprofen insufficient 1

Migraine Headache

• Aspirin: 325 mg daily 1
• Ibuprofen: 600 mg four times daily 1
• Naproxen sodium: 220 mg twice daily 1

Special Population Considerations

Elderly Patients

• Preferred agents: NSAIDs with lower renal excretion and phase 2 metabolism (acemetacin, diclofenac, etodolac) are less likely to induce adverse effects 2
• Avoid indomethacin in elderly due to reduced coronary flow 1
• Use lowest effective dose as elderly tolerate peptic ulceration or bleeding less well 3
• Monitor renal function closely as elderly are more likely to have decreased renal function 3

Cardiovascular Disease

• Preferred agents: Naproxen or celecoxib for patients with high cardiovascular risk 4
• Contraindicated: NSAIDs should not be administered to patients with NSTEMI/unstable angina 5
• Selective COX-2 inhibitors carry higher cardiovascular risk 2, 4

Hypertension

• Before starting NSAID, measure blood pressure 4
• For patients on renin-angiotensin system blockers, consider empirical addition of antihypertensive agent of different class 4
• Monitor blood pressure after therapy initiation 4

Renal Impairment

• Screen for unrecognized chronic kidney disease in high-risk cases before NSAID initiation 4
• Avoid NSAIDs in severe chronic kidney disease 4
• NSAIDs with lower renal excretion (acemetacin, diclofenac, etodolac) preferred 2
• Monitor renal function in most cases 4

Gastrointestinal Risk

• Moderate risk: Non-selective NSAID plus proton pump inhibitor (PPI), OR selective COX-2 inhibitor alone 4
• High risk: Selective COX-2 inhibitor plus PPI 4
• Lowest GI risk agent: Ibuprofen 1
• Young patients or those with active/chronic symptomatic gastritis: selective COX-2 inhibitors (celecoxib or etoricoxib) preferred 2

Critical Safety Considerations

Gastroprotection

• Always provide gastroprotection with NSAID therapy 1
• H2 blockers, misoprostol, and proton pump inhibitors reduce risk of NSAID-induced duodenal ulcers 1
• Misoprostol and proton pump inhibitors also reduce risk of other serious upper GI injury 1

Monitoring Requirements

• Measure blood pressure before initiating therapy 4
• Monitor blood pressure and renal function after starting NSAIDs 4
• Use serum CRP to guide treatment length and assess response in pericarditis 1
• Screen for unexplained iron-deficiency anemia before treatment 4

Duration Limits

• Ketorolac: Maximum 5 days 1
• Acute pericarditis: 1-2 weeks for uncomplicated cases, with tapering 1
• Colchicine adjunct: 3 months when used with NSAIDs for pericarditis 1

Common Pitfalls to Avoid

• Do not use indomethacin in elderly due to coronary flow reduction 1
• Avoid acetaminophen-codeine combinations due to metabolism variability, decreased effectiveness, and increased side effects 1
• Do not prescribe NSAIDs to patients with recent NSTEMI - mortality risk increases significantly (HR 1.50 for ibuprofen, 2.40 for diclofenac) 5
• Avoid corticosteroids as first-line for pericarditis due to risk of chronic evolution and drug dependence 1
• Do not use high-dose corticosteroids if needed; use prednisone 0.2-0.5 mg/kg/day instead of 1.0 mg/kg/day 1