NSAIDs work by inhibiting cyclooxygenase enzymes and reducing prostaglandin production, which decreases inflammation, pain, and fever. They are used to treat conditions like arthritis, postoperative pain, fever, and headaches. NSAIDs can be non-selective inhibitors of COX-1 and COX-2, preferential COX-2 inhibitors, or selective COX-2 inhibitors. Common NSAID drugs include aspirin, ibuprofen, naproxen, diclofenac, celecoxib, and etoricoxib.

1. NSAIDS (NON-STEROIDAL ANTI-INFLAMMATORY DRUGS)
NSAIDS are the drugs that reduce inflammation, pain & fever
by inhibiting the synthesis of prostaglandins & related
compounds.
NSAID inhibits cyclooxygenase 1 or 2 or both enzymes.
NSAIDS have three major actions:
 Analgesic
 Antipyretic
 Anti-inflammatory
Uses:
• Postoperative Pain
• Menstrual Pain
• Myalgia/Neuralgia
• Headache/Backache
• Pyrexia(Fever)
• Osteoarthritis
• Rheumatoid Arthritis
• Anti-platelet

2. There are two forms of cyclooxygenase, cyclooxygenase-1 (COX-1)
and cyclooxygenase-2 (COX-2).
COX-1: Produced by normal cells & tissues, maintains homeostasis
COX-2: Induced by inflammed cells, mediates inflammation

4. Functions Of Prostaglandins
• Directly Cause Pain
• Enhances Pain Inducing Effects Of Bradykinin
• Induces Fever
Functions Of Thromboxanes
• Cause platelets to aggregate
• Causes vasoconstriction
• Enhances function of inflammatory cells
Functions Of Histamines
• Causes tissue congestion & swelling
• Causes bronchoconstriction
• Causes sneezing, watery eyes, itching
• Causes pressure & pain
Functions Of Leukotrienes
• Increases vessel permiability and leakiness
• Stimulates platelet aggregation

5. Pain & Fever during Inflammation
Pain: PGE2 sensitize nerve terminal to the action of
bradykinin, PG, histamine and other local
mediators released from inflamed tissue & cause
pain.
Fever: Pyrogen, Cytokine (WBC), IL and chemical
mediators are activated during inflammation,
infection and diseases condition which stimulate PG
synthesis in hypothalamus and temperature set up
point is raised.
Analgesic, Anti-pyretic & Anti-inflammatory action
is due to inhibition of inflammatory mediators;
prostaglandins, histamines, thromboxanes and
leukotrienes.

7. Inflammation is the body’s response towards
injurious stimulus. It is a protective response
involving immune cells and chemical mediators.
Inflammatory response includes calor (warmth),
dolor (pain), rubor (redness), and tumor
(swelling).
Why inflammation should be controlled?
Inflammation can exaggerate & become harmful
Extremely inconvenience to patient
To reduce the symptoms like fever & pain

8. Non-Selective COX inhibitors
• Aspirin
• Ibuprofen
• Flurbiprofen
• Naproxen
• Mephenamic acid
• Piroxicam
• Ketolorac
• Indomethacin
• Phenylbutazone

9. Preferential COX-2 Inhibitors
• Nimesulide
• Meloxicam
• Etodolac
• Diclofenac
• Aceclofenac
Selective COX-2 Inhibitors
• Celecoxib
• Etoricoxib
• Parecoxib
Analgesic but poor anti-inflamatory
• Paracetamol (Acetaminophen)
• Metamizol
• Nefopam

10. ASPIRIN (ACETYLSALICYLIC ACID)
MOA: Aspirin is non selective inhibitor of cox enzymes and
supress prostaglandin synthesis.
Indication:
• Mild to moderate pain
(headache, backache, joint pain, toothache, dysmenorrhoea)
Aspirin 600mg=Codeine 60mg=Morphine 6mg
• Antipyretic in fevers
• Anti inflammatory in acute rheumatic fever, rheumatoid
arthritis, osteoarthritis
• Antiplatelet agent in atherosclerotic diseases, post-operative,
myocardial infarction, post stroke patients
• Aspirin is prescribed in a small dose as a means to lower the
risk of heart attack (prevents clotting action of platelets)
• Dose: 300-600mg TDS analgesic, antipyretic & anti-
inflammatory action
75-150mg OD myocardial infarction/stroke

11. Adverse effects
• Gastric mucosal damage, peptic ulcer
• Hypersensitivity
• Salicylism—dizziness, tinnitus, vertigo, reversible
impairment of hearing and vision, excitement and mental
confusion, hyperventilation and electrolyte imbalance.
• Liver injury
• Acute salicylate poisoning
Contraindication
• Peptic ulcer
• Bleeding disorder
• Hypersensitivity to NSAIDs
• Under 12 children
• Liver disease
• Pregnancy and lactation
• Chickenpox of influenza infection

12. PARACETAMOL (ACETAMINOPHEN)
MOA: Paracetamol inhibits the synthesis of prostaglandins in the
CNS by inhibiting COX 1 & 2 enzymes in the brain. Thus it inhibits
prostaglandin synthesis in hypothalamus & temperature set up
point is reduced. It also increases pain threshold & reduces pain.
It has less effect on COX enzyme in peripheral tissues, which
account for their weak anti-inflammatory activity.
Indications:
Over The Counter (OTC) drug for:
• Fever
• Headache
• Musculoskeletal Pain
• Dysmenorrhoea
• Osteoarthritis
Dose: Adult 325-1000mg 4-6 hourly or SOS (650mg rectally)
Child 10-15mg/kg 4-6 hourly; Safe in Pregnancy!

13. Paracetamol is Safe and Well Tolerated!
Adverse Effects
Over doses causes:
• Liver & kidney damage
• Gastric irritation, mucosal erosion & bleeding
• Rashes
• Nausea, Vomiting and Sweating
Contraindication
• Hypersensitivity
• Peptic ulcer
• Abuse of alcohol

14. NIMESULIDE
MOA: Nimesulide is an anti-inflammatory, analgesic,
and antipyretic that selectively inhibits COX-2 and
weakly inhibits PG synthesis.
Indications:
Short-lasting painful inflammatory conditions/sports injuries
• Sinusitis
• Dental surgery
• Bursitis
• Fever
Dose: 100mg BD
• Low backache
• Dysmenorrhoea
• Postoperative pain
• Osteoarthritis

15. Adverse Effects
• Gastrointestinal (epigastralgia, heart burn,
nausea, loose motions)
• Dermatological (rash, pruritus)
• Central (somnolence, dizziness)
• Hepatic Failure
Contraindication
• Liver toxicity/ Hepatic failure on long term use
• Pregnancy & Breastfeeding
• Children under 12 years of age

16. IBUPROFEN
MOA: Ibuprofen inhibits the COX enzymes and supresses the
synthesis of prostaglandins which are mediators of pain,
inflammation, and fever. It also inhibits the thromboxane
A2 which stimulates platelets aggregation & formation of
blood clot.
Indications: Over The Counter (OTC) Drug
• Fever
• Dysmenorrhoea
• Osteoarthritis
• Rheumatoid arthritis
• Musculoskeletal disorders
• Headache, Backache, Toothache
• Postpartum and Postoperative pain
Dose: 400-800mg TDS (children 20mg/kg/day)

17. Adverse Effects:
• Gastric discomfort, nausea and vomiting
• Gastric erosion and occult blood loss
• Dizziness, blurring of vision, tinnitus
• Rashes, itching and other hypersensitivity
Contraindication:
• Peptic ulcer
• Pregnancy & Lactation
• Children under 7 years
• Hypersensitivity

18. DICLOFENAC SODIUM
MOA: Diclofenac inhibits the synthesis of prostaglandins by
inhibiting COX enzymes and leucocyte migration. It is
somewhat COX-2 selective so it has better anti-inflammatory
action. It is also a potent analgesic preferred in mild to
moderate pain.
Indications:
• Quick relief of pain and edema, Toothache
• Rheumatoid arthritis, Osteoarthritis
• Dysmenorrhoea (menstrual pain)
• Bursitis (pain in shoulder, hip and elbow)
• Ankylosing spondylitis (inflammation in vertebra)
• Postoperative or post-traumatic pain and inflammation
• Ocular inflammation and pain
Dose: 50mg TDS, 75mg deep i.m

19. Adverse effects:
• Epigastric pain, nausea, headache, dizziness
• Rashes
• Gastric ulceration and bleeding
• Hepatic and Renal damage
Contraindications:
• Peptic ulcer
• Children under 7 years of age
• Kidney disease
• Liver disease
• Inflammatory bowel disease
• Patients with bleeding disorder
Aceclofenac: Similar in action with Diclofenac with fewer side
effects and better tolerability. Dose: 100mg BD

20. NSAIDS USES DOSE
Ketorolac Postoperative pain, inflammation 15-30mg i.m or
i.v
Indomethacin Acute GOUT, Rheumatoid arthritis,
Ankylosing spodylitis
25-50mg TDS
Naproxen Rheumatoid arthritis, Ankylosing
spodylitis
250-500mg BD
Piroxicam Osteoarthritis, Rheumatoid arthritis,
Ankylosing spodylitis
10-20mg OD
Mefenamic
acid
Muscle, Joint, Tissue Pain
Dysmenorrhoea, Rheumatoid
arthritis, Osteoarthritis
250-500mg
TDS
Celecoxib Selective COX-2 Inhibitors
Anti-inflammatory
”
100-200mg
OD-BD
Etoricoxib 60-120mg OD