Intended for healthcare professionals

Practice Therapeutics

Non-steroidal anti-inflammatory drugs (NSAIDs) for musculoskeletal pain

BMJ 2021; 372 doi: (Published 29 January 2021) Cite this as: BMJ 2021;372:n104
  1. Gustavo C Machado, research fellow1 2,
  2. Christina Abdel-Shaheed, research fellow1 2,
  3. Martin Underwood, professor3 4,
  4. Richard O Day, professor5 6
  1. 1Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
  2. 2Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
  3. 3Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
  4. 4University Hospitals Coventry and Warwickshire, Coventry, UK
  5. 5Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Sydney, Australia
  6. 6St Vincent’s Clinical School, University of New South Wales, Sydney, Australia
  1. Correspondence to: G C Machado gustavo.machado{at}

What you need to know

  • Oral non-steroidal anti-inflammatory drugs (NSAIDs) can reduce musculoskeletal pain but increase the risk of gastrointestinal (perforation, ulcers, bleeding), cardiovascular (myocardial infarction, heart failure, hypertension), and renal adverse events

  • Topical NSAIDs are also effective for osteoarthritis, with fewer adverse events than oral formulations

  • Opioids do not provide greater pain relief than NSAIDs for musculoskeletal pain and may cause serious harms such as dependence

A 65 year old patient has been troubled with intermittent low back pain for years, for which you prescribed ibuprofen 400 mg up to three times daily as needed. For the past four months, persistent knee pain, not associated with stiffness, has limited his mobility. He is overweight, physically inactive, and has recently been diagnosed with hypertension. Paracetamol has had little benefit. He asks if taking ibuprofen regularly might ease his knee pain.

What are non-steroidal anti-inflammatory drugs (NSAIDs)?

NSAIDs are commonly used for pain management. They reduce inflammation and pain by reducing the activity of cyclo-oxygenase (or COX) enzymes and inhibiting prostaglandin synthesis.1

  • Older, non-selective NSAIDs such as ibuprofen, diclofenac and naproxen inhibit both COX-1 and COX-2 enzymes

  • Newer, selective NSAIDs (COX-2 inhibitors, coxibs) such as celecoxib and etoricoxib selectively inhibit COX-2, which plays a greater role in prostaglandin mediated pain and inflammation.

The National Institute for Health and Care Excellence (NICE) guidelines recommend NSAIDs as first line analgesics for low back pain and sciatica2 and osteoarthritis.3 They are also used for musculoskeletal pain from acute injury. In England there were about 11.5 million prescriptions for oral NSAIDs in 2018.4 In the US around 60% of patients with osteoarthritis or chronic low back pain are prescribed NSAIDs, based on analysis of records in a claims database in 2008.5

Search strategy

We searched PubMed (NLM database) and the Cochrane Library with the terms “non-steroidal anti-inflammatory drugs” OR “NSAIDs” AND “spinal pain” OR …

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