choosing an NSAID or cox-2 inhibitor

Last reviewed 07/2021

The various NSAIDs have similar analgesic and anti-inflammatory effects.

60% of patients will respond to any NSAID.

However a significant minority of patients may find different drugs are more or less tolerable or effective.

First line NSAIDS include:

  • ibuprofen:
    • low incidence of side-effects
    • good for pain
    • less anti-inflammatory
  • naproxen and diclofenac:
    • more anti-inflammatory effects
    • relatively low incidence of side-effects

A MeReC review has issued guidance on the use of NSAIDs/COX-2 inhibitors in clinical practice.

  • where NSAIDs are required
    • prescribing should be based on the safety profiles of individual NSAIDs and on individual patient risk factors
    • all NSAIDs should generally be used at the lowest effective dose and for the shortest period of time necessary to control symptoms
  • low-dose ibuprofen (400mg three-times daily) is an appropriate first choice NSAID in view of its low risk for GI and CV side effects
  • the prescriber should consider using a PPI with any NSAID to reduce the risk of adverse GI effects
    • this is especially for those who are at high GI risk (includes anybody aged 65 years or over) and regular NSAID users
  • cox-2 inhibitors are associated with a lower risk of GI side effects than traditional NSAIDS
    • however is no good evidence to support the use of cox-2 inhibitors alone ahead of traditional NSAIDs when co-prescribed with a PPI and they have a higher CV risk than ibuprofen or naproxen
  • medication reviews of NSAIDs should consider (1):
    • is an NSAID still necessary?
    • is the NSAID prescribed appropriate based on the patients CV risk?
    • is the NSAID prescribed the one with the lowest GI risk suitable for that patient?
    • should a PPI be co-prescribed to reduce adverse GI effects?
    • when should treatment/dose next be reviewed?
  • when reviewing the treatment of patients already receiving diclofenac, some patients, after discussion, may decide to continue treatment with diclofenac. However, in some cases (especially patients with risk factors for CV disease) it may be appropriate to consider alternatives: -
    • patients who change from diclofenac 150mg/day to 1200mg ibuprofen daily would probably reduce both their GI and CV thrombotic risk
      • particularly if the a PPI is introduced
    • patients who change from diclofenac 150mg/day to naproxen 1000mg/day would reduce their CV thrombotic risk
      • however there may be a slight increase in their risk of GI complications
        • if there is however also a PPI introduced together with the change from diclofenac to naproxen then GI risks may also be reduced
      • there is less evidence for the balance of risks with lower doses of diclofenac and naproxen


  • high doses of ibuprofen (e.g. 2400mg/day) are not prescribed frequently in clinical practice, and the relative risks versus diclofenac are unclear.


  • (1) MeReC Extra 2007;30.