MSK & Rheumatology/NSAID

NSAIDs

also: ibuprofen · naproxen · diclofenac · COX inhibitor · celecoxib

Overview

Cross-cutting analgesic/anti-inflammatories — OA, gout, RA flares, dysmenorrhoea, acute pain. The GI/renal/cardiac/asthma cautions and the "triple whammy" are core.

Mechanism

Inhibit cyclo-oxygenase (COX-1/COX-2) → ↓prostaglandin synthesis → anti-inflammatory, analgesic, antipyretic. COX-1 inhibition causes the GI/renal/platelet effects; COX-2-selective agents (celecoxib) spare the gut but raise cardiovascular risk.

Indications

Inflammatory & musculoskeletal pain (OA, RA flare, gout, back pain)
Dysmenorrhoea / menorrhagia (cross-ref O&G)
Acute pain / antipyresis

The agents

Ibuprofenlower CV/GI risk

Preferred for short-term use.

Naproxenlowest CV risk

Preferred if cardiovascular risk.

Diclofenachigher CV risk

Avoid in cardiovascular disease.

CelecoxibCOX-2 selective

Less GI bleeding but ↑CV risk.

Adverse effects

GI ulceration / bleedingserious

Co-prescribe a PPI in at-risk patients; worse with steroids/anticoagulants/SSRIs.

Renal impairment / AKIserious

"Triple whammy" = NSAID + ACEi/ARB + diuretic → AKI.

Cardiovascular risk (MI, stroke, fluid retention)serious

Bronchospasm in aspirin-sensitive asthmacommon

Cautions & contraindications

Active peptic ulcer / GI bleedingall

Significant renal impairment / heart failurerenal

NSAID + ACEi/ARB + diureticall

Triple-whammy AKI.

Aspirin/NSAID hypersensitivity (asthma)asthma

3rd-trimester pregnancypregnancy

Premature ductus closure, oligohydramnios.

Interactions

ACEi/ARB + diuretic (AKI); anticoagulants/antiplatelets/SSRIs (bleeding); lithium/methotrexate (↑levels)

Monitoring & kinetics

Renal function in at-risk; GI symptoms; BP

Oral/topical/PR. Lowest effective dose, shortest duration; gastroprotection if at risk.

Source: NICE CKS — NSAIDs · BNF — NSAIDs