Considerations for NSAID use

To reduce the need for oral NSAIDs, consider:

• lifestyle measures and nonpharmacological therapies (eg psychological techniques, physical activity, social connection)
• a trial of oral paracetamol
• short-term use of a topical NSAID or other topical preparation (eg heat rub).

Assess the individual benefit–harm profile of an NSAID in each patient.

Avoid NSAIDs in patients with:

• active peptic ulcer disease or gastrointestinal bleeding
• a GFR of less than 30 mL/minute
• cirrhosis
• bone marrow impairment (eg haematological malignancy).

Avoid long-term use of NSAIDs in patients with a GFR of 30 to 60 mL/minute unless the patient has no other risk factors for acute kidney injury and there is no alternative treatment available.

If possible, avoid NSAIDs in patients:

• with established cardiovascular disease (eg heart failure, stroke) or at high risk of cardiovascular disease
• with an increased risk of gastrointestinal or cardiovascular toxicity
• treated with systemic corticosteroids. Concurrent use significantly increases the risk of gastrointestinal toxicity, and NSAIDs are unlikely to have additional benefit [NB1].

Consider if an NSAID is appropriate for:

• older people—assess the need for an NSAID carefully
• patients taking other drugs that may cause a drug–drug interaction.

If prescribing an NSAID:

• Choose an NSAID to trial based on patient factors
• Use the minimum effective dose for the shortest time possible.
• Do not use more than one NSAID at a time, except for coadministration with low-dose aspirin if it is clinically indicated for other reasons.
• For patients with risk factors for increased gastrointestinal toxicity with an NSAID or who are likely to be treated with an NSAID long term, consider co-prescribing a PPI for prophylaxis and testing for Helicobacter pylori (see Patients who have an increased risk of gastrointestinal toxicity).
• Encourage patients taking an NSAID long-term to address lifestyle -risk factors for gastrointestinal toxicity (eg tobacco smoking, obesity) and cardiovascular disease.
• Monitor treatment response, adverse effects and the ongoing need for an NSAID. Do not continue NSAIDs if there is no benefit or treatment is harmful.
  • Children, especially those of preschool age, may not display obvious symptoms of gastrointestinal intolerance to NSAIDs. Less obvious symptoms, such as irritability or loss of appetite, may be the only clues to NSAID intolerance.
  • Pseudoporphyria (photosensitivity causing facial skin blisters and scarring) is a well-recognised adverse reaction to naproxen, which is described mainly in children. If this occurs, immediately stop naproxen.
• Periodically consider a trial of dose tapering or treatment cessation.