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REMEDY : BNSSG referral pathways & Joint Formulary

BNSSG Adult Joint Formulary

10.4 Pain and inflammation in musculoskeletal disorders

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First line drugs Second line drugs Specialist drugs Secondary care drugs


Non-steroidal anti-inflammatory drugs

Link to BNF Non-steroidal anti-inflammatory drugs

  • See MHRA guidance on Cardiovascular Safety of Cox-2 inhibitors and non-selective NSAIDs
  • Please also refer to NICE guidance CG177 and NICE guideline NG100
  • Healthcare professionals should consider offering paracetamol for pain relief in addition to core treatments; regular dosing may be required. Paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, cyclooxygenase 2 (COX-2) inhibitors or opioids.
  • The combination of a NSAID and low-dose aspirin can increase the risk of gastrointestinal side-effects; this combination should be used only if absolutely necessary and the patient should be monitored closely.
  • NSAIDs should be used at the lowest effective dose and long term use should be avoided.


Ibuprofen (TLS Green)

Naproxen (TLS Green)

Alternatives: (TLS Blue)




Specific indications: (TLS Blue)

Mefenamic acid

  • Menorrhagia / dysmenorrhoea


  • For use by anaesthetic staff only






Topical NSAIDs

Recommended: (TLS Green)

Ibuprofen 5% gel - use should be reviewed after 14 days

Alternative: (TLS Blue)

Piroxicam 0.5% gel


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