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 (especially where NSAIDs are unlikely to be effective [e.g. neuropathic pain])?
• Does the person have a contraindication to all oral NSAIDs?
• Is gastroprotection indicated?
• Is there a reason for closer monitoring for adverse effects?
• What is the optimum dose and duration?
• Is there a reason for more frequent review of the continued need for an NSAID?

In depth

• Do not use NSAIDs in people with:
• A history of hypersensitivity/severe allergic reaction to an NSAID (including aspirin):
• Severe skin reactions and angioedema. Allergies that cause skin reactions and angioedema are absolute contraindications to NSAIDs.
• Asthma. Unless NSAIDs clearly cause severe exacerbations of asthma, people with asthma should not be denied the benefits of NSAIDs without being offered the option of a trial to assess the effect on asthma control.
• Severe heart failure — NSAIDs may impair renal function.
• Severe hepatic impairment (e.g. liver enzyme levels more than three times the upper limit of the normal range; serum albumin < 25g/L ).
• Current treatment for gastrointestinal bleeding, symptomatic peptic ulcer, or gastrointestinal perforation or obstruction.
• Coxibs are also contraindicated in people with ischaemic heart disease, cerebrovascular disease, peripheral arterial disease, moderate or severe heart failure.
• Where possible, avoid using NSAIDs in people with:
• Renal failure, with estimated glomerular filtration rate less than 30–15 mL/min/1.73 m², creatinine clearance less than 30–20 mL/min, or dehydration:
• Check the summary of product characteristics for the manufacturer's recommendation for each NSAID, available at the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk).
• Ideally, avoid using an NSAID.
• NSAIDs can provoke acute renal failure if given to someone who is dehydrated, especially if they have diabetes.
• NSAIDs should be used with caution in:
• The elderly — increased risk of serious adverse effects such as gastrointestinal bleeding and perforation, which may be fatal.
• People with a history of peptic ulceration (standard NSAIDs contraindicated), or those at high risk of gastrointestinal adverse effects.
• People with inflammatory bowel disease — NSAIDs may increase the risk of developing or cause exacerbations of ulcerative colitis or Crohn's disease.
• People with hepatic impairment — increased risk of gastrointestinal bleeding and fluid retention.
• Dose reduction is recommended for some NSAIDs.
• Check the summary of product characteristics for the manufacturer's recommendation for each NSAID, available at the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk).
• Renal impairment (avoid if possible) — sodium and water retention may occur leading to a deterioration in renal function and, possibly renal failure. This has also been reported with topical use.
• If the person cannot avoid using a NSAID and has impaired renal function, monitor creatinine clearance or estimated glomerular filtration rate.
• People with heart failure — NSAIDs may impair renal function.
• People with hypertension — NSAIDs may impair renal function.
• In a women trying to conceive — may impair female fertility.
• For information on when NSAIDs can be used during pregnancy, and which are preferred see Can NSAIDs be used during pregnancy?
• For information on when NSAIDs can be used during breastfeeding, and which are preferred see Can NSAIDs be used during breastfeeding?
• Consider the possibility of drug interactions.

In depth

• The risks of adverse effects vary among individual NSAIDs and are also often influenced by the dose and duration of use.
• Adverse effects may be minimized by using the lowest effective dose for the shortest duration necessary to control symptoms.
• Children appear to tolerate NSAIDs better than adults and gastrointestinal adverse effects are less common.
• The most common adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs) are:
• Dyspepsia and other upper gastrointestinal complications such as ulcer, perforation, obstruction or bleeding.
• For detailed information about who is at risk of how they can be managed, see the section Gastrointestinal adverse effects.
• Other less common adverse effects include:
• Cardiovascular and renal complications such as myocardial infarction, stroke, cardiac failure, hypertension, and renal failure are less common but serious adverse effects associated with NSAIDs.
• For detailed information about who is at risk of how they can be managed, see the section Cardiovascular and renal adverse effects.
• Prolonged bleeding (for example after surgery) because of platelet inhibition.
• Asthma — NSAIDs may exacerbate or precipitate asthma.
• Stop the NSAID if is suspected to have precipitated bronchospasm.
• Severe skin reactions and angioedema — stop the NSAID.
• Very rarely, NSAIDs can precipitate severe hepatic reactions (such as hepatitis, liver necrosis, or hepatic failure).
• If there are symptoms or signs of liver damage (e.g. nausea, vomiting, abdominal pain, jaundice), or persistently abnormal liver enzymes, stop the NSAID.

In depth

• Enquire about, and manage, adverse effects.
• Etoricoxib — blood pressure should be checked within 2 weeks of starting etoricoxib, and periodically thereafter.
• Consider the risks and the response to treatment, and use clinical judgement to decide what must be monitored and how frequently:
• People with ischaemic heart disease, risk factors for cardiovascular disease, cerebrovascular disease, peripheral vascular disease, and the elderly.
• Consider monitoring blood pressure, renal function, and features of cardiac failure.
• Heart failure
• Consider monitoring features of heart failure (such as body weight, jugular venous distension, crepitations, hepatomegaly, ascites, peripheral oedema) 1–2 weeks after starting or increasing the dose of the NSAID.
• Consider monitoring renal function (creatinine clearance or estimated glomerular filtration rate) 1–2 weeks after starting or increasing the dose of the NSAID, particularly in people taking an ACE inhibitor, an angiotensin-II receptor antagonist, a diuretic, or in those with impaired renal function.
• If, at any time, heart failure or renal impairment deteriorates, consider the NSAID as a cause .
• Hypertension
• Consider monitoring blood pressure (for example 2–4 weeks after starting or increasing the dose of the NSAID).
• Blood pressure should be checked within 2 weeks of starting etoricoxib, and periodically thereafter.
• If, at any time, hypertension control deteriorates, consider the NSAID as a cause.
• Renal impairment
• Consider monitoring renal function (creatinine clearance or estimated glomerular filtration rate) 1–2 weeks after starting or increasing the dose of the NSAID, and then regularly thereafter.
• If, at any time, renal impairment deteriorates, consider the NSAID as a cause.
• Hepatic impairment
• Enquire about adverse effects; NSAIDs increase the risk of gastrointestinal bleeding and fluid retention.
• Check the summary of product characteristics (SPC) for the nonsteroidal anti-inflammatory drug for more specific advice.
• Consider seeking specialist advice in case of uncertainty.

In depth

• When prescribing a nonsteroidal anti-inflammatory drug (NSAID), provide advice on:
• The option to purchase oral ibuprofen over the counter.
• The type of NSAID prescribed (standard NSAIDs or coxib).
• The risk of adverse effects:
• All people are at risk of adverse effects, but some people may be at increased risk.
• All NSAIDs have risks of adverse effects, but some NSAIDs may have higher risks for particular adverse effects.
• The need to weigh up, in each individual, the benefits of the prescribed NSAID against its risks and the person's ability to tolerate it.
• The main serious adverse effects (gastrointestinal, cardiovascular, renal, and hepatic).
• Strategies to minimize the risks of adverse effects, including:
• Using an alternative treatment to an oral NSAID.
• Using an NSAID at the lowest effective dose and for no longer than is necessary.
• Not to take an NSAID on an empty stomach.
• Using a gastroprotective strategy for people at increased risk of gastrointestinal adverse effects.
• Using a topical NSAID for knee or small joint disorders.
• Closer monitoring of people at increased risk.
• The need to carefully read the information leaflet enclosed with the medication.

In depth