What are the guidelines for using Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in patients with multiple sclerosis (MS)?

NSAID Use in Multiple Sclerosis

NSAIDs can be used safely in MS patients for musculoskeletal pain and treatment-related symptoms, but they are not effective for neuropathic pain syndromes and should be avoided for chronic pain management in MS patients with fibromyalgia-like symptoms. 1, 2

Pain Classification in MS

Before considering NSAIDs, determine the pain type, as this fundamentally changes treatment approach:

• Neuropathic pain (burning, tingling, shooting pain) requires gabapentin, pregabalin, or tricyclic antidepressants as first-line agents 1, 3, 2
• Musculoskeletal pain (diffuse body aches without neurological features) may respond to acetaminophen or NSAIDs 1, 2
• Treatment-related pain from interferon injections can be managed with NSAIDs 2, 4

Appropriate NSAID Use in MS

Acceptable Indications

NSAIDs have specific, limited roles in MS pain management:

• Interferon-related systemic symptoms: Paracetamol, ibuprofen, or naproxen effectively reduce flu-like symptoms and myalgias from interferon therapy 2, 4
• Malposition-induced joint and muscle pain: NSAIDs may be useful as adjunctive therapy alongside physiotherapy for mechanical pain from mobility impairment 2, 4
• Short-term musculoskeletal pain: For non-neuropathic body aches, NSAIDs can provide symptomatic relief 2

Critical Limitations

NSAIDs should be avoided for chronic pain management in MS patients with fibromyalgia-like symptoms due to lack of efficacy. 1 This is a common pitfall—assuming all MS pain responds to anti-inflammatory agents when most chronic MS pain is neuropathic in origin. 1, 2

Cardiovascular Risk Considerations

If NSAIDs are necessary in MS patients with cardiovascular disease or risk factors, apply a strict hierarchy:

• First-line alternatives: Begin with acetaminophen, nonacetylated salicylates, or tramadol 5
• If NSAIDs required: Use naproxen at the lowest effective dose for the shortest duration, as it has the most favorable cardiovascular profile (relative risk 0.92) 5
• Avoid: Diclofenac (relative risk 1.63) and COX-2 selective inhibitors, which carry significantly higher cardiovascular risk 5

The cardiovascular risk is proportional to COX-2 selectivity and underlying patient risk. 5 In post-MI patients, mortality hazard ratios were 2.80 for rofecoxib, 2.57 for celecoxib, 1.50 for ibuprofen, and 2.40 for diclofenac. 5

Treatment Algorithm for MS Pain

For neuropathic-type pain (most common chronic MS pain):

• Start with pregabalin, gabapentin, or tricyclic antidepressants (nortriptyline, desipramine) 1, 3, 2
• NSAIDs are ineffective and should not be used 1

For musculoskeletal-type pain:

• Start with acetaminophen 1
• If insufficient after 4 weeks, consider short-term NSAIDs (preferably naproxen) 1, 5
• Avoid long-term NSAID monotherapy beyond 3 months 6

For interferon-related symptoms:

• Use paracetamol, ibuprofen, or naproxen as needed for flu-like symptoms 2, 4

Common Pitfalls to Avoid

• Assuming all MS pain is neuropathic: Diffuse body aches without neurological features may respond better to acetaminophen than neuropathic agents 1
• Using NSAIDs for chronic neuropathic pain: This is ineffective and delays appropriate treatment with gabapentin, pregabalin, or antidepressants 1, 2
• Polypharmacy without monotherapy trials: Trial single agents for at least 4 weeks before adding combination therapy 1
• Ignoring cardiovascular risk: All NSAIDs carry cardiovascular risk proportional to COX-2 selectivity; naproxen is preferred when NSAIDs are necessary 5