NSAIDs
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Dosing and administration[2]
Symptomatic anti-inflammatory analgesics, not disease-modifying. Use the lowest effective dose for the shortest duration; co-prescribe gastroprotection (a proton pump inhibitor) in patients at gastrointestinal risk. Caution in cardiovascular and renal disease. In osteoarthritis, topical NSAIDs are preferred first-line for knee and hand OA (safer than oral) and oral NSAIDs are also strongly recommended; in axial spondyloarthritis, NSAIDs are first-line and may be used continuously in persistently active disease.
| Agent | Route | Dose and frequency |
|---|---|---|
| Ibuprofen | Oral | 400 to 800 mg three to four times daily; maximum about 3200 mg/day. |
| Naproxen | Oral | 250 to 500 mg twice daily; maximum about 1000 to 1500 mg/day. |
| Celecoxib (COX-2 selective) | Oral | 100 to 200 mg twice daily, or 200 mg once daily. |
| Diclofenac | Oral | 50 mg two to three times daily, or 75 mg twice daily; maximum about 150 mg/day. |
| Meloxicam | Oral | 7.5 to 15 mg once daily. |
| Topical diclofenac (Voltaren gel, Pennsaid) | Topical | Voltaren 1% gel: 2 g to each hand, wrist, or elbow, or 4 g to each knee, ankle, or foot, four times daily (do not exceed 32 g/day across all joints). Pennsaid solution: 40 drops of the 1.5% form four times daily, or 2 pump actuations of the 2% form twice daily, per affected knee. Preferred first-line for knee and hand osteoarthritis given lower systemic exposure. |
Renal adjustment. Avoid or use with caution in renal impairment, heart failure, and volume depletion (risk of acute kidney injury); avoid combining with an ACE inhibitor or ARB plus a diuretic.
Hepatic. Caution in hepatic impairment.
NSAIDs relieve symptoms but do not modify disease; in inflammatory arthritis they are adjuncts to DMARDs, not substitutes. In osteoarthritis and axial spondyloarthritis, though, NSAIDs are a core part of symptom control: topical NSAIDs first for knee and hand OA, and NSAIDs first-line (sometimes continuous) for axial spondyloarthritis.
Monitoring
- Blood pressure, renal function, and hemoglobin periodically with regular use.
- Assess gastrointestinal and cardiovascular risk before and during use.
Contraindications
- Active peptic ulcer or gastrointestinal bleeding.
- Severe heart failure; recent coronary artery bypass surgery.
- Severe renal impairment.
- Third trimester of pregnancy.
- Aspirin- or NSAID-induced asthma or hypersensitivity.
Key interactions
- Anticoagulants and antiplatelets: increased bleeding risk.
- ACE inhibitors, ARBs, and diuretics: reduced renal function.
- Lithium and methotrexate: raised levels.
- Reduced efficacy of antihypertensives.
Clinical notes
Common side effects
Gastrointestinal irritation is common; renal effects, blood-pressure elevation, and longer-term gastrointestinal and cardiovascular risk with sustained use. Not sourced on this draft.
Tests and monitoring
With regular use, monitor blood pressure and renal function; consider gastroprotection in at-risk patients. Thresholds to confirm from primary sources.
Important cautions
Caution with peptic ulcer disease, chronic kidney disease, cardiovascular disease, and anticoagulation, and in older adults; multiple interactions. To confirm from primary sources.
Primary sources to be used
- Primary sources for general (non-pregnancy) use to be attached: product monograph and the relevant ACR/EULAR treatment guideline.
- Standard doses from the respective Health Canada product monographs for ibuprofen, naproxen, celecoxib (Celebrex), diclofenac, and meloxicam. https://health-products.canada.ca/dpd-bdpp/
- Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol. 2020;72(2):220-233. doi:10.1002/art.41142 https://doi.org/10.1002/art.41142
- Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042 https://doi.org/10.1002/art.41042
- Topical diclofenac (Voltaren Emulgel and Pennsaid) product labeling and Health Canada product monographs; dosing corroborated with the Arthritis Society Canada drug guide. https://health-products.canada.ca/dpd-bdpp/