🩹 NSAIDs are effective analgesic, anti-inflammatory, and antipyretic agents.
🦴 Commonly used for musculoskeletal, rheumatological, and inflammatory pain.
⚠️ Benefits must be balanced against GI, renal, and cardiovascular risks.
💧 Can cause sodium and water retention → worsening heart failure and hypertension.
✅ Ibuprofen and diclofenac are among the safer traditional NSAIDs, but still carry significant risk.

🧠 Prescribing principle: Use the lowest effective dose for the shortest duration.

⚙️ Mode of Action (COX Inhibition)

🔬 NSAIDs inhibit cyclooxygenase (COX) enzymes → reduced prostaglandin synthesis.
COX-1 (Housekeeping Enzyme)
- Produces protective prostaglandins (PGE₂, PGI₂).
- Maintains gastric mucosa, renal perfusion, platelet function.
COX-2 (Inflammatory Enzyme)
- Induced in inflammation.
- Responsible for pain, swelling, fever.
💊 Traditional NSAIDs inhibit COX-1 and COX-2.
🎯 COX-2 inhibitors (coxibs) spare gastric mucosa but ↑ CV risk.
🧪 Aspirin irreversibly inhibits COX; others act reversibly.

🎯 Indications

🦴 Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis.
🩸 Rheumatic fever.
🎗️ Malignancy with bone pain.
🏥 Post-operative pain.
🚽 Renal colic.
🤕 Headache, migraine, dental pain.
🔥 Acute gout.

🚫 Contraindications & Cautions

⛔ Avoid / Extreme Caution
- Chronic kidney disease.
- Heart failure.
- Uncontrolled hypertension.
- Active peptic ulcer or GI bleed.
- Bleeding disorders.
⚠️ Cardiovascular Risk
- Avoid COX-2 inhibitors in IHD, stroke, PAD.
- Use lowest dose possible in CV disease.
💊 Drug-Related Caution
- Warfarin.
- Steroids.
- Lithium.
- Methotrexate.
👶 Aspirin
- Avoid in <16 years → Reye’s syndrome risk.

⚠️ Side Effects

🍽️ Gastrointestinal
- Dyspepsia, nausea, vomiting.
- Gastritis, ulcers, GI bleeding.
🩸 Platelet Effects
- Prolonged bleeding time.
- ↓ Thromboxane A₂.
😮‍💨 Hypersensitivity
- Bronchospasm.
- Urticaria.
- Rhinitis (AERD).
🧠 CNS
- Tinnitus.
- Dizziness.
- Hearing disturbance.
🫀 Renal
- AKI.
- Interstitial nephritis.
- Fluid retention.

📉 Risk Factors for NSAID-Related Ulcers

📆 Age >60 (especially >75).
🩺 Previous PUD or GI bleed.
💊 High-dose or multiple NSAIDs.
💉 Concomitant steroids.
❤️ Combined aspirin use.
🚬 Smoking, alcohol excess.

🛡️ Strategies to Reduce GI Risk

🎯 Consider non-NSAID analgesia first.
💊 Use COX-2 inhibitor if appropriate.
🛡️ Add PPI (e.g. omeprazole 20 mg OD).
💡 Consider H₂-blocker if PPI unsuitable.
⚠️ Misoprostol (200 mcg BD) in selected cases.

🔁 Drug Interactions

🩸 Warfarin → ↑ bleeding.
💊 Antihypertensives/diuretics → ↓ effect.
🧠 Lithium → ↑ toxicity.
🧪 Methotrexate → ↑ marrow toxicity.
⚡ K-sparing diuretics → ↑ hyperkalaemia.

🩺 Practical Prescribing Tips

Start low, review frequently.
Avoid in dehydration and sepsis.
Check U&Es before and after initiation in at-risk patients.
Always consider gastroprotection.
Document risk–benefit discussion.

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Non steroidal anti inflammatory drugs (NSAIDs) 💊

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