Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Major NSAID toxicity
Haematemesis, melaena, syncope, severe epigastric pain, oliguria, acute breathlessness, rapidly increasing oedema, anaphylaxis or severe wheeze after an NSAID may represent bleeding, perforation, acute kidney injury, heart failure or hypersensitivity.
Action: Stop the NSAID, arrange emergency assessment and resuscitation appropriate to the syndrome, check the complete medicine list and renal function, and do not substitute another NSAID until the cause and future analgesic plan have been reviewed.
Synopsis
Select topical and oral analgesia for rheumatic pain in a stepwise way, prescribe the lowest-risk effective NSAID course, and prevent gastrointestinal, renal, cardiovascular and pregnancy-related harm.
Treat the cause and function, not the pain score alone: define whether pain is inflammatory, mechanical, neuropathic, referred or an emergency before choosing an analgesic.
First-line for knee osteoarthritis is a topical NSAID alongside therapeutic exercise; consider topical treatment for other joints before exposing the whole body to an oral NSAID.
When oral NSAID treatment is necessary, use the lowest effective dose for the shortest possible time and co-prescribe a proton-pump inhibitor while the NSAID is taken.
Key red flags
Vomiting blood, black stools, collapse, unexplained anaemia or a rigid tender abdomen requires urgent assessment for gastrointestinal haemorrhage or perforation.
Upper gastrointestinal toxicity
Dyspepsia is an unreliable warning; ulcer bleeding may first present with melaena, haematemesis, syncope or iron-deficiency anaemia, especially in older or anticoagulated patients.
Investigation priorities
01
First-line clinical and medicine reviewFirst stepFirst line
Establish the pain mechanism, functional target and every prescription or non-prescription analgesic before adding treatment.
Management branches
First-line local strategyStart with diagnosis, movement and topical treatment
Localised peripheral joint pain has no emergency feature and topical treatment is suitable.
Agree a measurable function such as walking, sleep or hand use and begin exercise, load modification, physiotherapy or disease-specific therapy.
For knee osteoarthritis offer a topical NSAID first; apply the licensed amount to intact skin and avoid simultaneous oral NSAID exposure.
Key medicines
Diclofenac 1.16% gelFor adults and adolescents aged 14 years or over, apply 2–4 g to the painful area three or four times daily, according to area size, for no more than seven days without medical advice under this product licence.
NaproxenA common adult inflammatory-pain regimen is 250–500 mg orally twice daily with or after food; use the lowest effective dose for the shortest course and stay within the indication-specific product maximum.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.