What are the recommended oral Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for pain management?

Recommended Oral NSAIDs for Pain Management

For mild to moderate pain, start with ibuprofen 400-800 mg every 6 hours (maximum 2400 mg/day) or naproxen 250-500 mg twice daily, as these are the most appropriate first-line oral NSAIDs based on their favorable safety profiles and established efficacy. 1, 2

First-Line NSAID Selection Algorithm

Ibuprofen as Primary Choice

• Ibuprofen is the lowest-risk NSAID for serious gastrointestinal complications among non-selective NSAIDs 3
• Start with 400 mg every 6 hours for acute pain, or 1200 mg daily divided for chronic inflammatory conditions 2, 3
• Maximum daily dose: 2400 mg 2
• Ibuprofen achieves high analgesic effect at doses with low anti-inflammatory activity, making it less ulcerogenic than other NSAIDs 3

Naproxen as Alternative

• Naproxen is the safest NSAID regarding cardiovascular risk, particularly compared to COX-2 selective agents 4
• Dosing: 250-500 mg twice daily due to longer half-life allowing convenient twice-daily administration 5
• Naproxen is as effective as aspirin in rheumatoid arthritis but better tolerated 5
• For older adults with low gastrointestinal risk requiring NSAID therapy, ibuprofen or naproxen are specifically recommended over other NSAIDs 3

Pain Type-Specific Recommendations

Inflammatory Pain and Bone Pain

• NSAIDs are particularly effective for inflammatory pain and bone pain in cancer patients 1
• Paracetamol/acetaminophen and NSAIDs are effective for treating all intensities of pain, at least in the short term unless contraindicated 1

Mild Pain (WHO Level I)

• Use acetaminophen/paracetamol or an NSAID as first-line 1
• Selective COX-2 inhibitors may be considered for patients with gastric intolerance, though toxicity concerns and limited efficacy data exist for cancer pain 1

Moderate to Severe Pain

• NSAIDs can be combined with weak opioids (WHO Level II) or strong opioids (WHO Level III) 1
• Continue NSAID therapy alongside opioid escalation for additive analgesic benefit 1

Critical Safety Considerations and Monitoring

High-Risk Populations Requiring Caution

• Patients over 60 years have increased risk of all NSAID-related adverse effects 2
• History of peptic ulcer disease carries 5% risk of recurrent bleeding within 6 months even with protective measures 2
• Concomitant anticoagulant use increases GI bleeding risk 5-6 fold 2
• Male gender, concurrent corticosteroid therapy, and advanced age increase upper GI bleeding and perforation risk 1

Gastrointestinal Protection Strategy

• Co-prescribe proton pump inhibitors to reduce gastrointestinal side effects in all patients on NSAIDs 1, 3
• One-year risk of serious GI bleeding ranges from 1 in 2,100 in adults <45 years to 1 in 110 in adults >75 years 2

Renal and Cardiovascular Precautions

• Prescribe NSAIDs with caution in patients older than 60 years, those with compromised fluid status or renal insufficiency, or when given with nephrotoxic drugs and renally excreted chemotherapy 1
• Both ibuprofen and naproxen may adversely affect blood pressure control, renal function, and heart failure management 3
• Monitor blood pressure, BUN, creatinine, liver function tests, and complete blood count in patients on long-term high-dose therapy 2

Absolute Contraindications

• Aspirin/NSAID-induced asthma 2
• Perioperative pain in coronary artery bypass graft surgery 2
• Patients with renal dysfunction, heart failure, cirrhosis should avoid or use extreme caution 2
• History of asthma attack, hives, or allergic reaction with aspirin or any NSAID 6

Mandatory Discontinuation Criteria

Stop NSAID immediately if:

• Gastrointestinal bleeding occurs 2
• BUN or creatinine doubles 2
• Hypertension develops or worsens 2
• Liver function tests increase above normal limits 2

Prescribing Principles

• Use the lowest effective dose for the shortest duration necessary 2, 3, 4
• Prescribe analgesics on a regular schedule, not "as required" for chronic pain 1
• The oral route should be advocated as first choice 1
• Provide rescue doses for breakthrough pain episodes 1

Common Pitfalls to Avoid

• Do not use high-dose ibuprofen (2400 mg/day) without recognizing that GI bleeding risk becomes comparable to other NSAIDs at full anti-inflammatory doses 3
• Do not overlook acetaminophen as first-line therapy—it should be tried before any NSAID for non-inflammatory pain conditions 3
• Do not prescribe NSAIDs in patients with low creatinine clearance, gastropathy, cardiovascular disease, or congestive heart failure without careful risk-benefit assessment 3
• Avoid COX-2 selective agents (celecoxib, etoricoxib) and diclofenac due to increased cardiovascular risk 4
• Do not continue NSAIDs beyond 10 days without medical supervision for over-the-counter use 6