Choosing an NSAID

Australian and New Zealand College of Anaesthetists (ANZCA), 2020O'Neil, 2012Pope, 1993

The risk of individual adverse effects varies between nonsteroidal anti-inflammatory drugs (NSAIDs). If an NSAID is suitable for management of a patient’s musculoskeletal pain (see Principles of prescribing NSAIDs for musculoskeletal pain); individualise NSAID choice based on patient characteristics (eg comorbidities, age).

The inhibition of prostaglandins cyclo-oxygenase-1 (COX-1) and COX-2 is thought to contribute to the adverse effect profile of NSAIDs. NSAIDs that selectively bind to COX-1 usually have a higher risk of causing gastrointestinal toxicity, while NSAIDs that selectively bind to COX-2 may have a higher risk of causing a cardiovascular event, especially at higher doses. Route of administration, and coadministration with food has no influence on the adverse effect profile of NSAIDs.

In particular, NSAID choice should be individualised or avoided in the following patient groups:

NSAID choice by patient risk summarises NSAID choice based on a patient’s cardiovascular and gastrointestinal risk.

Table 1. NSAID choice by patient risk

Patients at low risk of experiencing a cardiovascular event

Patients at high risk of experiencing a cardiovascular event

Patients at low risk of experiencing gastrointestinal adverse effects [NB1]

choose any NSAID

celecoxib at doses of 200 mg or less

naproxen at doses of 500 mg twice daily or less

ibuprofen at doses of 1200 mg daily or less

Patients at high risk of experiencing gastrointestinal adverse effects [NB1]

celecoxib at doses of 200 mg daily or less [NB2]

meloxicam at doses of 7.5 mg daily or less [NB2]

avoid all NSAIDs if possible

Note:

NB1: Risk factors for NSAID-induced upper gastrointestinal bleeding or perforation are listed in Risk factors for NSAID-induced upper gastrointestinal bleeding or perforation.

NB2: The concomitant use of low-dose aspirin eliminates any upper gastrointestinal safety advantage of celecoxib and meloxicam.