7th January 2024

NSAIDs

NSAIDs’ anti-inflammatory effect is through Cyclo-Oxygenase (COX) inhibition, reducing prostaglandin synthesis. This reduces inflammation-induced nociceptive pain. This is particularly effective in visceral and somatic nociceptive pain.

Ibuprofen is available over the counter with a typical starting dose of 400mg three times daily. Naproxen is a commonly used NSAID with a starting dose of 500mg twice daily.

Proton pump inhibitors should be prescribed alongside NSAIDs due to the risk of peptic ulcer disease and gastropathy. This is less likely at lower doses. NSAIDs should be used with caution in renal impairment, thrombocytopenia, and cardiac dysfunction.

COX-2 selectivity

COX-2 is associated with painful inflammation, whereas COX-1 is more physiological. There are more than 20 NSAIDs grouped based on the selectivity of COX-1 or 2 inhibition. Ibuprofen and Naproxen are non-selective, whereas Diclofenac is a preferential COX-2 inhibitor.

Celecoxib is a more selective COX-2 inhibitor, which may be utilised in bone pain or soft tissue disease. The starting dose is 100mg twice daily, which can be uptitrated to 200mg twice daily. Celecoxib has a lower risk of GI side effects and is the Palliative Care Formulary’s NSAID of choice.