What NSAID (Non-Steroidal Anti-Inflammatory Drug) is recommended for pain relief?

Recommended NSAID for Pain Relief

For general pain relief in adults, ibuprofen 400 mg is the recommended first-line NSAID, offering optimal efficacy with the lowest cardiovascular and gastrointestinal risk profile among NSAIDs. 1, 2

Stepped-Care Approach to Pain Management

First-Line Treatment

• Start with acetaminophen (paracetamol) up to 4 g daily before considering any NSAID 1
• Acetaminophen has fewer side effects than NSAIDs and should be the initial analgesic for mild to moderate pain 1
• This approach is particularly important for patients with cardiovascular disease or risk factors 1

Second-Line: NSAID Selection

If acetaminophen fails to provide adequate relief, ibuprofen 1.2 g daily (400 mg three times daily) should be substituted 1

Why Ibuprofen is Preferred:

• Lowest gastrointestinal risk among all NSAIDs 1
• Lower cardiovascular risk compared to other NSAIDs 1
• Proven efficacy with NNT of 2.5 for at least 50% pain relief at 400 mg dose 2
• Doses of 400 mg, 600 mg, and 800 mg show similar analgesic efficacy, making higher doses unnecessary 3

Alternative NSAIDs (Third-Line)

If ibuprofen at 1.2-2.4 g daily remains inadequate:

• Naproxen is a reasonable alternative as it appears to have relatively lower cardiovascular risk compared to other non-selective NSAIDs 1
• Diclofenac and other NSAIDs may be considered but carry higher cardiovascular risk 1

Critical Safety Considerations

Cardiovascular Risk Hierarchy

The cardiovascular risk increases with COX-2 selectivity 1:

• Ibuprofen: HR 1.50 (lowest among commonly used NSAIDs) 1
• Naproxen: HR 1.29 1
• Diclofenac: HR 2.40 1
• Celecoxib: HR 2.57 1
• All NSAIDs should be used at the lowest effective dose for the shortest duration 1, 4

Special Populations Requiring Extra Caution

Patients with Cardiovascular Disease

• NSAIDs should be limited to situations with no appropriate alternatives 1
• In post-MI patients, excess mortality risk is 6 deaths per 100 person-years with COX-2 inhibitors 1
• Monitor blood pressure and renal function closely 1

Patients on Aspirin for Cardioprotection

• Critical interaction with ibuprofen: Ibuprofen interferes with aspirin's antiplatelet effect 1
• Timing protocol for immediate-release aspirin + ibuprofen 400 mg: Take ibuprofen either ≥30 minutes after aspirin OR ≥8 hours before aspirin 1
• No reliable recommendations exist for enteric-coated aspirin with ibuprofen 1
• Diclofenac does NOT interfere with aspirin's antiplatelet effect 1

Cancer Pain

• Paracetamol and/or NSAIDs are effective for mild pain and can be combined with opioids at any step of the WHO ladder 1
• Long-term NSAID use requires careful monitoring for gastrointestinal bleeding, platelet dysfunction, and renal failure 1

Gastrointestinal Protection

• Ibuprofen has the lowest GI risk among NSAIDs 1
• Prophylactic gastroprotection is generally not warranted for routine osteoarthritis patients but should be considered for high-risk individuals 1
• Misoprostol and proton pump inhibitors reduce risk of NSAID-induced ulcers 1

Dosing Recommendations

Ibuprofen Dosing Strategy

• Initial dose: 400 mg every 6-8 hours (1.2 g/day) 1
• If inadequate relief: Increase to 2.4 g/day OR add acetaminophen up to 4 g/day 1
• Higher single doses (600-800 mg) provide no additional analgesic benefit over 400 mg 3
• Duration of action: approximately 4.7-5.4 hours for 200-400 mg doses 2

Common Pitfalls to Avoid

• Do not combine ibuprofen with aspirin without proper timing to avoid negating cardioprotection 1
• Do not use COX-2 selective inhibitors as first-line due to increased cardiovascular risk 1
• Do not prescribe NSAIDs long-term without physician consultation and regular monitoring 1, 4
• Do not exceed recommended doses as adverse events are dose-dependent 4
• Do not use NSAIDs in patients with renal disease, heart failure, or uncontrolled hypertension without careful risk-benefit assessment 1