The optimum nonsteroidal anti-inflammatory drug (NSAID) depends on the individual's risk factors, therapeutic response, and preferences. When prescribing an NSAID, consider:

• Is the person already using ibuprofen or aspirin in medication purchased without prescription?
• Is there an alternative to the NSAID? Alternative interventions may have a more favourable balance of benefits and risks. For example, consider:
• For pain relief: paracetamol, codeine, and other analgesics, especially if an NSAID is not likely to be effective for pain relief (e.g. neuropathic pain).
• For single regional pain relief (especially wrists, hands, knees, elbows, feet): a topical NSAID.
• For osteoarthritis: alternative analgesics (including paracetamol, codeine), topical NSAIDs, physical therapy, surgery.
• For gout: corticosteroids, colchicine.
• Does the person have a contraindication to oral NSAIDs?
• Is gastroprotection indicated? For example, if the person is:
• At increased risk of gastrointestinal adverse effects.
• Subject to dyspepsia from standard NSAIDs.
• Is there a reason for closer monitoring for adverse effects? For example, people who are:
• At risk for multiple adverse effects:
• Older age.
• Comorbidity.
• Potential interaction with other drugs being used.
• At increased risk of gastrointestinal adverse effects.
• At increased risk of cardiovascular or renal adverse events.
• What is the optimum dose and duration?
• For all NSAIDs, the lowest effective dose and the shortest duration of treatment should be used.
• Is there a reason for more frequent review of the continued need for an NSAID?
• All people using NSAIDs (continuously or intermittently) should have their indications for NSAID use regularly reviewed.
• People who are at increased risk of severe adverse effects should be reviewed more frequently:
• Use clinical judgement when deciding on the follow-up interval, taking into account the risk factors for adverse effects and progress of the underlying disease and any comorbidity.

For more information, see:

• Preventing GI adverse effects
• Managing GI adverse effects
• Monitoring
• Potentially hazardous interactions with other drugs

This approach to safe and effective prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) is based on the opinion of experts and on advice from the Commission on Human Medicines (CHM) and the Medicines and Healthcare products Regulatory Agency (MHRA) [CHM, 2006; MHRA, 2007; Stillman and Stillman, 2007; BNF 55, 2008]. The expert opinion and advice from the CHM and MHRA take into account a large body of evidence on the benefits and adverse effects of NSAIDs:

• Evidence on benefits:
• Evidence on the benefits of NSAIDs depends on the particular indication and is summarized within each CKS topic that offers NSAIDs as a treatment option, for example, in the CKS topics on Gout, Menorrhagia, and Osteoarthritis.
• Evidence on harms:
• Cardiovascular, renal, and gastrointestinal adverse effects of NSAIDs. The evidence on cardiovascular and renal adverse effects and on strategies for gastroprotection is summarized in separate sections:
• Risk of thrombotic adverse events
• Risk of cardiorenal adverse events
• Prevention of GI adverse effects
• In the absence of evidence from clinical trials, recommendations on general strategies for safe and effective prescribing are pragmatic advice based on expert opinion.