💡 Overview
- NSAIDs treat nociceptive and inflammatory pain (musculoskeletal, gout, dysmenorrhoea). Use the lowest effective dose for the shortest time.
- Do not combine two NSAIDs.
- Offer a PPI if there is GI risk: age over 65, previous ulcer, steroids, anticoagulants, antiplatelets, SSRIs, or high-dose / prolonged NSAID.
⚠️ Avoid or hold
- AKI, significant CKD, heart failure, severe hepatic impairment, active peptic ulcer, GI bleeding, previous NSAID-related GI bleed or perforation, and aspirin-sensitive asthma.
- Pregnancy: contraindicated in the third trimester. Avoid from 20 weeks unless essential (oligohydramnios, ductus arteriosus risk). Celecoxib, etoricoxib, and Arthrotec are contraindicated throughout pregnancy.
- Diclofenac, celecoxib, and etoricoxib: contraindicated in ischaemic heart disease, cerebrovascular disease, peripheral arterial disease, and heart failure (NYHA II–IV).
- Do not use for peri-operative analgesia after coronary artery bypass graft (CABG).
- NSAID with an ACEi or ARB and a diuretic increases AKI risk. Hold the NSAID if the patient is volume depleted (see Sick day rules).
- Anticoagulants and antiplatelets: bleeding risk rises. Do not start overnight without a senior plan and PPI cover.
- Methotrexate or lithium: NSAIDs can raise levels or toxicity (including with low-dose methotrexate if dehydrated or AKI). Do not start overnight without senior / pharmacy advice.
📋 Ward tips
- Naproxen or low-dose ibuprofen (up to 1.2 g/day) carry the lowest CV risk of the oral NSAIDs, but not zero. Use with care in established atherosclerotic disease.
- Keral (dexketoprofen): short-term acute pain only. Dose-reduce if CrCl 60–89 mL/min; avoid if CrCl ≤59 mL/min.
- Difene is a common Irish diclofenac brand (50 mg gastro-resistant capsules, 75 mg dual-release).
- Vimovo is naproxen 500 mg plus esomeprazole 20 mg. Swallow whole, at least 30 minutes before food. Delayed release makes it unsuitable for acute pain. Contraindicated if CrCl <30 mL/min.
- Topical NSAIDs (Voltarol Emulgel, Fastum) are a good option for localised musculoskeletal pain, as little reaches the bloodstream. Systemic effects become possible on large areas, broken skin, or under occlusion.
- Ibuprofen can reduce the antiplatelet effect of low-dose aspirin. Prefer another analgesic if they take aspirin for CV protection.
NSAIDs
Common Irish products
| Drug | Dose | Frequency | Route | Notes |
|---|---|---|---|---|
| Non-selective NSAIDs | ||||
| Ibuprofen (Nurofen, Brufen) | 400 mg | TDS (max 2.4 g/day Rx) | PO | OTC max often 1.2 g/day. Take with food. Avoid in AKI, ulcer, NSAID-sensitive asthma, HF. May blunt low-dose aspirin. |
| Naproxen (Naprosyn) | 250–500 mg | BD (max 1 g/day) | PO | Gout: 500 mg BD until settling. Still has CV risk; use only after careful consideration if atherosclerotic disease. |
| Diclofenac (Voltarol) | 50 mg | TDS (max 150 mg/day) | PO / PR | Contraindicated in IHD, CVA, PVD, HF (NYHA II–IV). Retard 75–100 mg OD available. |
| Diclofenac (Difene 50 mg) | 50 mg | TDS (max 150 mg/day) | PO | Irish gastro-resistant capsules. |
| Diclofenac (Difene 75 mg dual-release) | 75 mg | OD (max BD) | PO | 25 mg gastro-resistant plus 50 mg prolonged-release. Swallow whole. |
| Dexketoprofen (Keral) | 25 mg | TDS (max 75 mg/day) | PO | Short-term only. Max 50 mg/day if CrCl 60–89; contraindicated if CrCl ≤59 mL/min. |
| Mefenamic acid (Ponstan Forte) | 500 mg | TDS | PO | Dysmenorrhoea and mild–moderate pain. Same NSAID cautions. |
| COX-2 selective | ||||
| Celecoxib (Celebrex) | 100–200 mg | BD (OA often 200 mg OD) | PO | Avoid if sulphonamide allergy. Contraindicated in IHD, CVA, PVD, HF (NYHA II–IV), IBD, CrCl <30, severe hepatic impairment, and pregnancy. |
| Etoricoxib (Arcoxia) | 30–90 mg (gout 120 mg) | OD (gout max 8 days) | PO | Gout only: 120 mg OD ≤8 days. Contraindicated in IHD, CVA, PVD, HF, uncontrolled hypertension, IBD, and pregnancy. |
| Combinations | ||||
| Vimovo (naproxen 500 mg / esomeprazole 20 mg) | 1 tablet | BD | PO | Swallow whole, 30 min before food. Do not add another NSAID. Contraindicated if CrCl <30. Same naproxen cautions. |
| Arthrotec (diclofenac / misoprostol) | 50/200 or 75/200 mg | BD–TDS (50); OD–BD (75) | PO | Misoprostol: diarrhoea, cramps; abortifacient. Contraindicated in pregnancy; contraception required if pregnancy possible. |
| Topical and parenteral | ||||
| Diclofenac gel (Voltarol Emulgel) | Per SmPC | 2–4 times daily | Topical | Lower systemic exposure. Still an NSAID if large area or broken skin. |
| Ketoprofen gel (Fastum) | Per SmPC | 2–3 times daily | Topical | Photosensitivity: cover treated skin and avoid sun/UV. |
| Dexketoprofen (Keral injection) | 50 mg | Up to TDS, max 2 days | IM / IV | Then switch to oral. Same NSAID cautions. |
Non-selective NSAIDs
Ibuprofen (Nurofen, Brufen)
PODose:400 mg
Frequency:TDS (max 2.4 g/day Rx)
Notes: OTC max often 1.2 g/day. Take with food. Avoid in AKI, ulcer, NSAID-sensitive asthma, HF. May blunt low-dose aspirin.
Naproxen (Naprosyn)
PODose:250–500 mg
Frequency:BD (max 1 g/day)
Notes: Gout: 500 mg BD until settling. Still has CV risk; use only after careful consideration if atherosclerotic disease.
Diclofenac (Voltarol)
PO / PRDose:50 mg
Frequency:TDS (max 150 mg/day)
Notes: Contraindicated in IHD, CVA, PVD, HF (NYHA II–IV). Retard 75–100 mg OD available.
Diclofenac (Difene 50 mg)
PODose:50 mg
Frequency:TDS (max 150 mg/day)
Notes: Irish gastro-resistant capsules.
Diclofenac (Difene 75 mg dual-release)
PODose:75 mg
Frequency:OD (max BD)
Notes: 25 mg gastro-resistant plus 50 mg prolonged-release. Swallow whole.
Dexketoprofen (Keral)
PODose:25 mg
Frequency:TDS (max 75 mg/day)
Notes: Short-term only. Max 50 mg/day if CrCl 60–89; contraindicated if CrCl ≤59 mL/min.
Mefenamic acid (Ponstan Forte)
PODose:500 mg
Frequency:TDS
Notes: Dysmenorrhoea and mild–moderate pain. Same NSAID cautions.
COX-2 selective
Celecoxib (Celebrex)
PODose:100–200 mg
Frequency:BD (OA often 200 mg OD)
Notes: Avoid if sulphonamide allergy. Contraindicated in IHD, CVA, PVD, HF (NYHA II–IV), IBD, CrCl <30, severe hepatic impairment, and pregnancy.
Etoricoxib (Arcoxia)
PODose:30–90 mg (gout 120 mg)
Frequency:OD (gout max 8 days)
Notes: Gout only: 120 mg OD ≤8 days. Contraindicated in IHD, CVA, PVD, HF, uncontrolled hypertension, IBD, and pregnancy.
Combinations
Vimovo (naproxen 500 mg / esomeprazole 20 mg)
PODose:1 tablet
Frequency:BD
Notes: Swallow whole, 30 min before food. Do not add another NSAID. Contraindicated if CrCl <30. Same naproxen cautions.
Arthrotec (diclofenac / misoprostol)
PODose:50/200 or 75/200 mg
Frequency:BD–TDS (50); OD–BD (75)
Notes: Misoprostol: diarrhoea, cramps; abortifacient. Contraindicated in pregnancy; contraception required if pregnancy possible.
Topical and parenteral
Diclofenac gel (Voltarol Emulgel)
TopicalDose:Per SmPC
Frequency:2–4 times daily
Notes: Lower systemic exposure. Still an NSAID if large area or broken skin.
Ketoprofen gel (Fastum)
TopicalDose:Per SmPC
Frequency:2–3 times daily
Notes: Photosensitivity: cover treated skin and avoid sun/UV.
Dexketoprofen (Keral injection)
IM / IVDose:50 mg
Frequency:Up to TDS, max 2 days
Notes: Then switch to oral. Same NSAID cautions.
SmPCs (medicines.ie / HPRA)
Ibuprofen Max 400 mgNurofenBrufen 400 mgBrufen 600 mgBrufen Retard 800 mgNaproxen (Naprosyn EC 500 mg, HPRA)Vimovo 500 mg/20 mgVoltarol 50 mgVoltarol Retard 75 mgVoltarol Retard 100 mgCataflam 50 mgDifene 50 mg (HPRA)Difene 75 mg dual-release (HPRA)Voltarol Emulgel 1%Arthrotec 50Arthrotec 75Keral 25 mg tabletsKeral 25 mg granulesKeral 50 mg injectionFastum 2.5% gelPonstan 250 mgPonstan Forte 500 mgCelebrex 100 mgCelebrex 200 mgArcoxiaEtoricoxib (Viatris)
Related NICE guidance
NICENICE NG148 — Acute kidney injury: prevention, detection and managementNICENICE CG141 — Acute upper gastrointestinal bleeding in over 16s: managementNICENICE NG219 — Gout: diagnosis and management (Jun 2022)
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
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