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NSAID Ceiling

Bryan Hayes, PharmD and Mike Weinstock, MD
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In this segment we discuss the ceiling effect of NSAIDs, the max dose at which pain relief is obtained. Higher doses and longer courses can lead to adverse effects without more pain control. The generally accepted ceiling dose for pain control is 600 mg for ibuprofen and 10 mg for ketorolac (IV/IM/PO). There may be more anti-inflammatory effect with higher doses in conditions such as rheumatoid arthritis.

Pearls:

  • The analgesic ceiling of ketorolac and ibuprofen is 10mg and 400mg respectively.

  • Acetaminophen and ibuprofen taken together can provide additional analgesic benefit than either medication alone.

  • Use the smallest effective dose for the shortest period of time to reduce side effects.

 

  • The “ceiling effect” is the concept that there exists a dose beyond which there is no additional analgesic benefit.

  • Laska EM, et al. The correlation between blood levels of ibuprofen and clinical analgesic response. Clin Pharmacol Ther. 1986;40(1):1-7.

    • Ibuprofen 400mg has equal analgesic effect when compared to ibuprofen 600mg and ibuprofen 800mg.

  • While the analgesic ceiling ibuprofen is 400mg, the dose response for conditions that are caused by inflammatory conditions is higher.

  • Ibuprofen and acetaminophen can be taken together at the same time for increased analgesic efficacy

  • Motov S, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2016.

    • Ketorolac at 10mg was just as effective as ketorolac 15mg and 30mg

  • Bally M, et al. Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ. 2017;357:j1909.

    • NSAID use is associated with an increased risk of myocardial infarction and stroke within the first week of use. The risk also increases with the duration and the dosage used.

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Pericarditis: Getting To The Heart Of The Matter Full episode audio for MD edition 177:10 min - 83 MB - M4AHippo Urgent Care RAP - February 2018 Written Summary 283 KB - PDF

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