However, it has more gastro-intestinal side-effects than
most other NSAIDs, and is associated with more frequent
serious skin reactions.
Meloxicam p.^658 is a selective inhibitor of cyclo-
oxygenase- 2. Its use may be considered in adolescents
intolerant to other NSAIDs.
Ketorolac trometamol p. 817 can be used for the short-
term management of postoperative pain.
Etoricoxib p. 653 , a selective inhibitor of cyclo-oxygenase-
2 , is licensed for the relief of pain in osteoarthritis,
rheumatoid arthritis, ankylosing spondylitis, and acute gout
in children aged 16 years and over.
Dental and orofacial pain
Most mild to moderate dental pain and inflammation is
effectively relieved by ibuprofen, diclofenac potassium or
diclofenac sodium.
NSAIDs and cardiovascular events
The risk of cardiovascular events secondary to NSAID use is
undetermined in children. In adults, all NSAID use
(including cyclo-oxygenase- 2 selective inhibitors) can, to
varying degrees, be associated with a small increased risk of
thrombotic events (e.g. myocardial infarction and stroke)
independent of baseline cardiovascular risk factors or
duration of NSAID use; however, the greatest risk may be in
those patients receiving high doses long term. A small
increased thrombotic risk cannot be excluded in children.
In adults, cyclo-oxygenase- 2 selective inhibitors,
diclofenac ( 150 mg daily) and ibuprofen ( 2. 4 g daily) are
associated with an increased risk of thrombotic events. The
increased risk for diclofenac is similar to that of etoricoxib.
Naproxen (in adults, 1 g daily) is associated with a lower
thrombotic risk, and lower doses of ibuprofen (in adults,
- 2 g daily or less) have not been associated with an
increased risk of myocardial infarction.
The lowest effective dose of NSAID should be prescribed
for the shortest period of time to control symptoms, and the
need for long-term treatment should be reviewed
periodically.
NSAIDs and gastro-intestinal events
All NSAIDs are associated with gastro-intestinal toxicity. In
adults, evidence on the relative safety of NSAIDs indicates
differences in the risks of serious upper gastro-intestinal
side-effects—piroxicam and ketorolac trometamol are
associated with the highest risk; indometacin, diclofenac,
and naproxen are associated with intermediate risk, and
ibuprofen with the lowest risk (although high doses of
ibuprofen have been associated with intermediate risk).
Selective inhibitors of cyclo-oxygenase- 2 are associated with
alower riskof serious upper gastro-intestinal side-effects
than non-selective NSAIDs.
Children appear to tolerate NSAIDs better than adults and
gastro-intestinal side-effects are less common although they
do still occur and can be significant; use of gastro-protective
drugs may be necessary.
Asthma
All NSAIDs have the potential to worsen asthma, either
acutely or as a gradual worsening of symptoms; consider
both prescribed NSAIDs and those that are purchased over
the counter.
ANALGESICS›NON-STEROIDAL ANTI-
INFLAMMATORY DRUGSDiclofenac potassium
lINDICATIONS AND DOSE
Pain and inflammation in rheumatic disease and other
musculoskeletal disorders
▶BY MOUTH
▶Child 14–17 years: 75 – 100 mg daily in 2 – 3 divided doses
Postoperative pain
▶BY MOUTH
▶Child 9–13 years (body-weight 35 kg and above):Up to
2 mg/kg daily in 3 divided doses; maximum 100 mg per
day
▶Child 14–17 years: 75 – 100 mg daily in 2 – 3 divided doses
Fever in ear, nose, or throat infection
▶BY MOUTH
▶Child 9–17 years (body-weight 35 kg and above):Up to
2 mg/kg daily in 3 divided doses; maximum 100 mg per
daylUNLICENSED USEVoltarol®Rapidnot licensed for use in
children under 14 years or in fever.
lCONTRA-INDICATIONSActive gastro-intestinal bleeding.
active gastro-intestinal ulceration.cerebrovascular
disease.history of gastro-intestinal bleeding related to
previous NSAID therapy.history of gastro-intestinal
perforation related to previous NSAID therapy.history of
recurrent gastro-intestinal haemorrhage (two or more
distinct episodes).history of recurrent gastro-intestinal
ulceration (two or more distinct episodes).ischaemic
heart disease.mild to severe heart failure.peripheral
arterial disease
lCAUTIONSAllergic disorders.cardiac impairment (NSAIDs
may impair renal function).coagulation defects.
connective-tissue disorders.Crohn’s disease (may be
exacerbated).history of cardiac failure.hypertension.left
ventricular dysfunction.oedema.risk factors for
cardiovascular events.ulcerative colitis (may be
exacerbated)
lINTERACTIONS→Appendix 1 : NSAIDs
lSIDE-EFFECTS
▶Common or very commonAppetite decreased.diarrhoea.
dizziness.gastrointestinal discomfort.gastrointestinal
disorders.headache.nausea.skin reactions.vertigo.
vomiting
▶UncommonChest pain.heart failure.myocardial
infarction.palpitations
▶Rare or very rareAcute kidney injury.agranulocytosis.
alopecia.anaemia.angioedema.anxiety.aplastic
anaemia.asthma.confusion.constipation.depression.
drowsiness.dyspnoea.erectile dysfunction.fatigue.
haemolytic anaemia.haemorrhage.hearing impairment.
hepatic disorders.hypersensitivity.hypertension.
hypotension.inflammatory bowel disease.irritability.
leucopenia.memory loss.meningitis aseptic (patients
with connective-tissue disorders such as systemic lupus
erythematosus may be especially susceptible).nephritis
tubulointerstitial.nephrotic syndrome.oedema.oral
disorders.pancreatitis.photosensitivity reaction.
pneumonitis.proteinuria.psychotic disorder.renal
papillary necrosis.seizure.sensation abnormal.severe
cutaneous adverse reactions (SCARs).shock.sleep
disorders.stroke.taste altered.thrombocytopenia.
tremor.vasculitis.vision disorders
▶Frequency not knownHallucination.malaise.optic
neuritis
lALLERGY AND CROSS-SENSITIVITYContra-indicated in
patients with a history of hypersensitivity to aspirin or anyBNFC 2018 – 2019 Pain and inflammation in musculoskeletal disorders 651
Musculoskeletal system10