NSAIDs for musculoskeletal conditions

There are about 20 different nonsteroidal anti-inflammatory drugs (NSAIDs) available. Some, such as aspirin and ibuprofen, are widely available over-the-counter (OTC). Others are only available on prescription. NSAIDs are the most frequently used medicines for symptomatic relief in osteoarthritis (OA), the most common form of arthritis, and are often prescribed to rheumatoid arthritis (RA) patients.

NSAIDs are usually effective for a few hours, but some are available in modified-release formulations to prolong their effective period. They can be used in combination with paracetamol (acetaminophen) or compound analgesics such as co-codamol if necessary.

NSAIDs should however be used with caution as they all pose the risk of side-effects, such as stomach ulcers, gastrointestinal bleeding, kidney failure, heart attacks, and strokes. Aspirin and naproxen are moderately more suitable for patients at risk of heart disease or stroke. Should long term use be warranted co-administration with a proton pump inhibitor (e.g. omeprazole or esomeprazole) to help protect against gastro-intestinal damage is advised.

Below is a short list of some of the more commonly prescribed NSAIDs used for symptomatic relief in rheumatic, musculoskeletal and soft tissue conditions. Here we focus on use in these conditions and do not discuss other licensed indications for these drugs.

Ibuprofen is licensed for controlling pain and inflammation in rheumatic disease and other musculoskeletal disorders and soft-tissue injuries. Ibuprofen can be used to treat juvenile idiopathic arthritis (JIA), but not in infants under 3 months (or with body weight <5kg). Ibuprofen is available OTC, as oral tablets (immediate and modified-release) and in topical gels. Ibuprofen is low-risk for causing stomach ulcers.

Aspirin treats symptoms of mild to moderate pain. Available OTC.

Naproxen is licensed for symptomatic relief in rheumatic disease, musculoskeletal disorders and acute gout. In the UK it is a prescription medicine in relation to the mentioned indications (but is available OTC for primary dysmenorrhoea).

Celecoxib is the only COX-2 selective NSAID on the market. It is a prescription only medicine licensed for treating the symptoms of pain and inflammation in OA and RA, and for the treatment of ankylosing spondylitis.

Diclofenac and indomethacin are prescription only NSAIDs, suitable for treating pain and inflammation in rheumatic disease, other musculoskeletal disorders and acute gout. Indomethacin is high-risk for causing stomach ulcers.

Mefenamic acid is also available on prescription to treat pain and inflammation in OA and RA.