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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.

NSAIDs, analgesia and gastroprotection

Rheumatology · UK scope · Sources checked 27 Aug 2026 · Clinical 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.
  • Do not combine oral NSAIDs, and count over-the-counter ibuprofen, cold remedies and topical products during medicine reconciliation.
  • A proton-pump inhibitor reduces upper gastrointestinal ulcer risk but does not prevent NSAID-associated acute kidney injury, fluid retention, cardiovascular events or lower-gastrointestinal injury.
  • Check previous ulcer or bleed, age and frailty, anticoagulants or antiplatelets, corticosteroids, kidney disease, dehydration, hypertension, heart failure, cardiovascular disease, asthma and pregnancy before prescribing.
  • Paracetamol has limited benefit for osteoarthritis and should not be a routine long-term substitute; NICE reserves it or a weak opioid for infrequent short-term use when other pharmacological options are ineffective or contraindicated.
  • Avoid strong opioids for osteoarthritis; if an opioid is exceptionally used, state the goal, duration, driving advice, constipation plan, review date and stop rule.
  • From 20 weeks of pregnancy, systemic NSAIDs should be avoided unless clinically necessary and then used briefly with obstetric advice; they are contraindicated in the final trimester under product information.
  • Reassess benefit within days to weeks: if pain and function have not meaningfully improved, stop the medicine rather than accumulating toxicity.

Key red flags

Vomiting blood, black stools, collapse, unexplained anaemia or a rigid tender abdomen requires urgent assessment for gastrointestinal haemorrhage or perforation.

New oliguria, confusion, dehydration, rising creatinine or hyperkalaemia after an NSAID requires immediate withdrawal and acute kidney injury assessment.

Acute dyspnoea, orthopnoea, chest pain, marked oedema or uncontrolled blood pressure may reflect fluid retention, heart failure or a cardiovascular event.

Wheeze, facial swelling, urticaria or hypotension soon after dosing suggests NSAID hypersensitivity and must be treated as an airway emergency when severe.

Pain that is nocturnal, progressive, associated with fever, a hot swollen joint, neurological loss, trauma or cancer features needs diagnosis rather than repeated analgesic escalation.

Any NSAID exposure from 20 weeks of pregnancy warrants obstetric and prescribing review because prolonged use can cause oligohydramnios and fetal ductal effects.

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.

Renal and fluid toxicity

Reduced urine, weight gain, oedema, worsening blood pressure, breathlessness or an intercurrent dehydrating illness should trigger NSAID cessation and renal or cardiac assessment.

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.

  1. Agree a measurable function such as walking, sleep or hand use and begin exercise, load modification, physiotherapy or disease-specific therapy.
  2. For knee osteoarthritis offer a topical NSAID first; apply the licensed amount to intact skin and avoid simultaneous oral NSAID exposure.
  3. Review local skin reaction, actual use and functional benefit; stop if benefit is absent rather than adding systemic exposure automatically.

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.Do not use on broken skin, in NSAID hypersensitivity, or with occlusion; wash hands, avoid eyes and excessive sunlight, and count systemic exposure if another NSAID is prescribed.
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.Avoid active ulcer or bleeding, severe kidney, liver or heart failure, aspirin-sensitive asthma and the final trimester of pregnancy; review anticoagulants, antiplatelets, ACE inhibitors, ARBs, diuretics and lithium.
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Sources and review status7 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

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.

  • NICE NG226 osteoarthritis recommendationsTopical-first analgesia, oral NSAID and PPI use, limited paracetamol and opioid roles.
  • MHRA NSAID risks after 20 weeks of pregnancyOligohydramnios, ductal constriction, duration minimisation and monitoring.
  • Naproxen 500 mg UK product informationLicensed doses, gastrointestinal, renal, cardiovascular and pregnancy cautions.
  • Voltarol 1.16% gel UK product informationTopical diclofenac regimen, age limits, skin use and systemic warnings.
  • Omeprazole 20 mg UK product informationNSAID ulcer prevention dose, contraindications and long-term safety.
  • NHS paracetamol for adultsAdult interval and maximum daily dose.
  • Codeine phosphate UK product informationLicensed adult dose, respiratory, dependence, driving and breastfeeding cautions.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem ·

Respiratory hypersensitivity

Bronchospasm, nasal symptoms, urticaria or angioedema after aspirin or another NSAID predicts cross-reactive risk and requires an allergy-aware alternative plan.

Content changes
Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom