NSAID Guidelines for Pain Management

Introduction to NSAID Use

For beginners in Indian general practice settings, ibuprofen 400-600 mg orally every 4-6 hours is the recommended first-line NSAID for most pain conditions, according to the American family physician guidelines 1
The American family physician recommends using the lowest effective dose for the shortest duration possible to minimize adverse effects 2

The recommended dosage for ibuprofen is 400-600 mg orally every 4-6 hours, with a maximum daily dose of 2400 mg, for musculoskeletal pain, headache, and dental pain 1
Naproxen is recommended at a dosage of 250-500 mg twice daily, with a maximum daily dose of 1500 mg, for osteoarthritis, rheumatoid arthritis, and longer-lasting pain relief, as suggested by the American family physician 2
The American College of Cardiology recommends considering naproxen for patients with cardiovascular disease, as it may have a better CV profile 5

For mild pain, start with paracetamol 500-1000 mg every 6 hours, and if insufficient, add or switch to ibuprofen 400 mg every 6 hours, as recommended by the Praxis Medical Insights guidelines 3
For moderate pain, use ibuprofen 400-600 mg every 6 hours or naproxen 500 mg twice daily, according to the American family physician guidelines 2
For severe pain, use diclofenac 50 mg three times daily or consider combination therapy (NSAID + paracetamol), as suggested by the Critical Care guidelines 1
For chronic conditions, such as osteoarthritis, use naproxen 500 mg twice daily or etodolac 300 mg twice daily, as recommended by the BMJ guidelines 4

In elderly patients (>60 years), use lower doses and prefer ibuprofen or naproxen, as recommended by the American family physician guidelines 2
In patients with a history of peptic ulcer, add a proton pump inhibitor (e.g., omeprazole 20 mg daily), according to the American family physician guidelines 2
In patients with renal impairment, avoid NSAIDs if possible, or use the lowest effective dose for the shortest duration, as suggested by the American family physician guidelines 2
In patients with cardiovascular disease, avoid NSAIDs if possible, and if necessary, consider naproxen, which may have a better CV profile, as recommended by the American College of Cardiology guidelines 5

Monitor baseline blood pressure, renal function, and liver function tests, and repeat every 3 months for long-term use, as recommended by the Journal of the National Comprehensive Cancer Network guidelines 6
Watch for GI symptoms, edema, or worsening hypertension, according to the Journal of the National Comprehensive Cancer Network guidelines 6
Always consider adding a PPI for patients on long-term NSAID therapy or those >60 years old, as recommended by the Journal of the National Comprehensive Cancer Network guidelines 6
Never prescribe two different NSAIDs simultaneously, as this increases toxicity without additional benefit, according to the Journal of the National Comprehensive Cancer Network guidelines 6