Choosing an analgesic regimen for patients at increased risk of NSAID-related toxicity

Consult with a medical practitioner if unsure of the safety of short-term use of an NSAID for a particular patient.

Recognise patients that should not be prescribed NSAIDs by a dentist (see Patients who should not be prescribed an NSAID by a dentist). If paracetamol is not expected to provide sufficient analgesia in these patients, consider alternative pain management strategies or refer the patient to a medical practitioner.

Recognise patients at increased risk of renal toxicity, and:

• consult a medical practitioner to determine if NSAID use is appropriate, unless paracetamol alone is expected to provide sufficient analgesia.

Recognise patients at increased risk of cardiovascular toxicity, and:

• consider that ineffective pain relief can cause tachycardia, which may cause adverse cardiovascular effects
• avoid diclofenac and COX-2–selective NSAIDs other than celecoxib
• use celecoxib or ibuprofen (naproxen can be used, but has a higher risk of gastrointestinal adverse effects) but limit treatment to 5 days
• if celecoxib, ibuprofen and naproxen cannot be used, use paracetamol alone for mild to moderate pain (see here for children or here for adults), or, in adults, paracetamol with oxycodone for severe pain (see here).

Recognise patients at increased risk of gastrointestinal toxicity, and:

• avoid nonselective NSAIDs (eg ibuprofen, diclofenac, naproxen)
• use a COX-2–selective NSAID (eg celecoxib)¹
• if a COX-2–selective NSAID cannot be used, use paracetamol alone for mild to moderate pain (see here for children or here for adults), or, in adults, paracetamol with oxycodone for severe pain (see here).

In patients who have had NSAID-induced bronchospasm:

• avoid nonselective NSAIDs (eg ibuprofen, diclofenac, naproxen)
• use a COX-2–selective NSAID (eg celecoxib).