Nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen (paracetamol): Usual oral dosing for adults with pain or inflammation and selected characteristics

Drug	Usual analgesic dose (oral)	Maximum dose per day	Selected characteristics
Nonselective NSAIDs^*
Acetic acids
Diclofenac^¶	50 mg every 8 to 12 hours	150 mg For rheumatoid arthritis, labeling in United States permits up to 200 mg Approved maximum in Canada is 100 mg	Dosing for free-acid preparation differs from doses listed here for sodium or potassium salts; refer to Lexicomp drug monograph
Etodolac	200 to 400 mg every 6 to 8 hours	1000 mg	Relative COX-2 selectivity and minimal effect on platelet function at lower total daily dose of 600 to 800 mg
Indomethacin	25 to 50 mg every 8 to 12 hours	150 mg For rheumatologic conditions, labeling in United States permits up to 200 mg	Used for treatment of acute gout and certain types of headache Potent inhibitory effects on kidney prostaglandin synthesis More frequently associated with CNS side effects (eg, headache, altered mental status) compared with other NSAIDs
Sulindac	150 to 200 mg every 12 hours	400 mg	Rarely used More frequently associated with hepatic inflammation than other NSAIDs Metabolites implicated in the formation of renal calculi
Fenamates
Meclofenamate (meclofenamic acid)	50 mg every 4 to 6 hours or 100 mg 3 times daily up to 6 days for dysmenorrhea	400 mg	Used for treatment of dysmenorrhea Relatively higher incidence of GI side effects
Mefenamic acid	250 mg every 6 hours or 500 mg 3 times daily	1000 mg For dysmenorrhea, up to 1500 mg	Used for treatment of dysmenorrhea; not indicated for treatment of chronic pain or inflammation Do not exceed 3 days (dysmenorrhea) to 7 days (acute pain) of use Less potent antiinflammatory effect
Nonacidic
Nabumetone	1000 mg once to twice daily	2000 mg	Relative COX-2 selectivity and minimal effect on platelet function at daily dose ≤1000 mg
Oxicams
Meloxicam^Δ	7.5 to 15 mg once daily (conventional tablet, oral suspension)	15 mg (conventional tablet, oral suspension)	Long duration of effect; relatively slow onset Relative COX-2 selectivity and minimal effect on platelet function at lower daily dose of 7.5 mg
Meloxicam^Δ	5 to 10 mg once daily (capsule)	10 mg (capsule)
Piroxicam	10 to 20 mg once daily	20 mg	Long-acting alternative for treatment of chronic pain and inflammation poorly responsive to other NSAIDs Prescribing generally limited to specialists with experience in treatment of chronic pain and inflammation
Propionic acids
Fenoprofen	200 mg every 4 to 6 hours or 400 to 600 mg every 6 to 8 hours	3200 mg	More frequently associated with acute interstitial nephritis and nephrotic syndrome^[1]
Flurbiprofen	50 mg every 6 hours or 100 mg every 8 to 12 hours	300 mg
Ibuprofen^Δ	400 mg every 4 to 6 hours or 600 to 800 mg every 6 to 8 hours	3200 mg (acute), 2400 mg (chronic)	Shorter-acting alternative to naproxen; useful in patients without cardiovascular risks
Ketoprofen	50 mg every 6 hours or 75 mg every 8 hours	300 mg
Naproxen	Base: 250 to 500 mg every 12 hours or 250 mg every 6 to 8 hours	Base: 1250 mg (acute); 1000 mg (chronic); may increase to 1500 mg during a disease flare	Often preferred by UpToDate for treatment of acute or chronic pain and inflammation in patients without relevant comorbidities or risks Higher dose (eg, 500 mg base twice daily) may have less cardiovascular toxicity than comparable doses of other NSAIDs;^[2] refer to UpToDate topic review of cardiovascular effects of nonselective NSAIDs Naproxen sodium has a faster onset than naproxen base
Naproxen	Naproxen sodium: 275 to 550 mg every 12 hours or 275 mg every 6 to 8 hours	Naproxen sodium: 1375 mg (acute); 1100 mg (chronic); may increase to 1650 mg during a disease flare
Oxaprozin	1200 mg once daily	1200 mg or 1800 mg depending on body weight (refer to Lexicomp drug monograph)	Prolonged half-life (41 to 55 hours); requires several days of treatment to reach full effect
Salicylate (acetylated)
Aspirin	325 to 1000 mg every 4 to 6 hours	4000 mg	Not commonly used for chronic pain and inflammation High daily doses have been used as antiinflammatory therapy; such use is limited by toxicity Irreversibly inhibits platelet function Refer to appropriate UpToDate clinical topics and Lexicomp drug monograph for other uses
Salicylates (nonacetylated)
Diflunisal	500 mg every 8 to 12 hours	1500 mg	No significant effect on platelet function at usual doses Relatively lower GI bleeding risk than other nonselective NSAIDs at usual doses May be tolerated at lower daily doses by adults with AERD or pseudoallergic reactions (eg, asthma, rhinosinusitis); refer to UpToDate topic reviews of allergic and pseudoallergic reactions to NSAIDs
Magnesium salicylate	1160 mg every 6 hours	4640 mg
Salsalate	1000 mg every 8 to 12 hours or 1500 mg every 12 hours	3000 mg
COX-2 selective NSAIDs
Celecoxib	200 mg daily or 100 mg every 12 hours	400 mg	Less risk of GI toxicity relative to nonselective NSAIDs; benefit negated by low-dose aspirin, which may require concurrent gastroprotection No effect on platelet function Cardiovascular and kidney risks are dose-related and may be similar to nonselective NSAIDs May be tolerated by patients with AERD or pseudoallergic reactions (eg, asthma, rhinosinusitis) who cannot take other NSAIDs; refer to UpToDate topic reviews of allergic and pseudoallergic reactions to NSAIDs
Etoricoxib (not available in the United States)	30 to 60 mg once daily	60 mg (chronic pain and inflammation) 120 mg (acute pain for up to 8 days)	May be associated with more frequent and severe dose-related cardiovascular effects (eg, hypertension) Other risks and benefits similar to celecoxib
Non-NSAID analgesic
Acetaminophen (paracetamol)^Δ	325 to 650 mg every 4 to 6 hours or 1000 mg every 6 hours up to 3 times daily	3000 mg 4000 mg in selected medically supervised patients Avoid or use a lower total daily dose (maximum 2000 mg) in older adults, patients at increased risk for hepatotoxicity (eg, regular alcohol use, malnourished), or patients with organ dysfunction	Effective for noninflammatory pain; may decrease opioid requirements Doses ≤2000 mg per day do not appear to increase risk of serious GI complications^[3] Does not alter platelet function Can cause hepatotoxicity in chronic or acute overdose To avoid overdose, warn patients about acetaminophen content in combination prescription (eg, oxycodone-acetaminophen) and nonprescription (OTC) preparations

NSAIDs are useful for treatment of acute and chronic painful and inflammatory conditions and may reduce opioid requirements. The indications for use of NSAIDs in specific disorders, adverse effects, and toxicities are presented in the relevant UpToDate topics including reviews of NSAID-associated adverse cardiovascular effects, gastroduodenal toxicity, acute kidney injury, etc.

UpToDate contributors generally avoid use of NSAIDs, or use them with particular caution and at reduced doses, in older adults and patients (regardless of age) with existing or increased risk for cardiovascular, GI, or kidney disease. Concurrent gastroprotection (eg, a proton pump inhibitor) may be warranted. For information on gastroprotective strategies, including use of selective COX-2 inhibitors and other options, refer to the UpToDate topic reviews of COX-2 selective NSAIDs and NSAIDs (including aspirin) and primary prevention of gastroduodenal toxicity.

Short- to moderate-acting NSAIDs (eg, naproxen, ibuprofen) are preferred for most patients. Use the lowest effective dose for the shortest duration of time. For chronic inflammatory conditions, a trial of ≥2 weeks is advised to assess full efficacy. For patients who experience an inadequate response to an NSAID of 1 class, it is reasonable to substitute an NSAID of another class.

Dosing in this table is for immediate-release preparations in patients with normal organ (eg, kidney) function. For treatment of acute pain, a loading dose of some NSAIDs may be used; refer to Lexicomp drug monographs.

Drug interactions may be determined by use of the Lexicomp drug interactions program included within UpToDate.

AERD: aspirin-exacerbated respiratory disease; CNS: central nervous system; COX-2: cyclooxygenase, isoform 2; GI: gastrointestinal; OTC: over the counter.

* Nonselective NSAIDs reversibly inhibit platelet function, with some exceptions noted above.

¶ Also available as a topical agent.

Δ Also available for parenteral use.

References:

Murray MD, Brater DC. Renal toxicity of the nonsteroidal anti-inflammatory drugs. Annu Rev Pharmacol Toxicol 1993; 33:435.
Bhala N, Emberson J, Merhi A, et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomized trials. Lancet 2013; 382:769.
McCrae JC, Morrison EE, MacIntyer IM, et al. Long-term adverse effects of paracetamol – a review. Br J Clin Pharmacol 2018; 84:2218.

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Nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen (paracetamol): Usual oral dosing for adults with pain or inflammation and selected characteristics