The role of NSAIDs in chronic noncancer pain
Evidence supporting long-term use of NSAIDs in chronic noncancer pain is limited and varies for specific chronic pain conditions. NSAIDs are more effective than paracetamol for chronic inflammatory conditions, but are associated with more adverse effects (some of which cause significant harm). Despite limited evidence supporting their use, if paracetamol has not been effective, a short-term trial of an NSAID may be considered for children or adults struggling to achieve a supported self-management approach. Due to the mechanism of action, an NSAID should only be trialled if a nociceptive component is suspected to be contributing to the pain; NSAIDs should not be trialled in neuropathic or nociplastic chronic pain conditions.
To reduce harm, NSAIDs should be prescribed at the lowest possible dose and for the shortest period of time. Seek specialist advice if the patient is at high risk of NSAID-related adverse effects. For detailed discussion of the role of NSAIDs in musculoskeletal inflammatory conditions, including adverse effects and prescribing considerations, see here.
Although the combination of paracetamol and NSAIDs brings additive benefit in acute nociceptive pain, this benefit has not been established in chronic pain.
If an NSAID is appropriate for adults with chronic noncancer pain, use:
1 celecoxib 100 to 200 mg orally, twice daily chronic noncancer pain (adults) celecoxib
OR
1 ibuprofen 200 to 400 mg orally, 3 times daily1 chronic noncancer pain (adults) ibuprofen
OR
1 naproxen 250 to 500 mg orally, twice daily2. chronic noncancer pain (adults) naproxen
If an NSAID is appropriate for children older than 3 months with chronic noncancer pain, use:
1 ibuprofen 5 to 10 mg/kg (for overweight children, use ideal body weight) up to 400 mg orally, 8-hourly. Maximum 30 mg/kg up to 1.2 g in 24 hours chronic noncancer pain (children) ibuprofen
OR
2 celecoxib 2 to 4 mg/kg (for overweight children, use ideal body weight) up to 100 mg orally, 12-hourly. Maximum 8 mg/kg daily up to 200 mg in 24 hours chronic noncancer pain (children) celecoxib
OR
2 naproxen 5 mg/kg (for overweight children, use ideal body weight) up to 500 mg orally, 12-hourly. Maximum 10 mg/kg up to 1 g in 24 hours. chronic noncancer pain (children) naproxen
If the NSAID is not tolerated or if no pain relief has occurred after 1 week, advise patients (or parents/carers) to stop the NSAID and to consult the prescriber for other management strategies. If the NSAID has provided adequate pain relief, advise the patient (or parent/carer) to consult the prescriber for a comprehensive assessment of analgesic efficacy and management goals after 4 weeks use. If it is appropriate to continue the NSAID (eg for an underlying pathology), trial deprescribing at each review or every 3 months to assess ongoing efficacy attributable to the NSAID, and reduce the risk of long-term adverse effects.