NSAID Utilization and Safety in Malaysia: A Literature Review

Abstract

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in Malaysia for pain and inflammatory conditions, yet their high utilization continues to raise important concerns regarding prescribing practices, public awareness, and safety. This literature review examined studies published between 2017 and 2025 to identify national trends in NSAID utilization, patterns of prescribing in clinical settings, and levels of knowledge, attitude, practice, and perception among healthcare workers, patients, and the general public, evaluate key safety concerns and adverse effects, and summarize evidence for improvement strategies and safer alternatives in Malaysia. Findings from utilization studies show extensive prescribing across primary care, hospitals, and community settings, including notable use among pediatric and postoperative orthopedic patients. Studies consistently indicate that many patients and members of the public have varying levels of knowledge, attitude, practice, and perception related to NSAID use, with common gaps in understanding safety risks. Evidence also shows ongoing concerns about adverse effects, particularly gastrointestinal complications, which remain a significant issue among NSAID users. At the same time, several studies demonstrate that educational interventions, clearer clinical recommendations, and the use of safer alternatives such as topical NSAIDs can help improve the safe and rational use of NSAIDs in Malaysia. Overall, the review underscores the need for rational prescribing, enhanced pharmacovigilance, and strengthened education strategies to promote safer and more responsible NSAID use in Malaysia.

Introduction

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used globally for their analgesic, anti-inflammatory, and antipyretic effects. They work mainly by inhibiting COX-1 and COX-2 enzymes, which regulate prostaglandin and thromboxane production. While COX-1 supports gastric, platelet, and renal protection, COX-2 is induced during inflammation and produces pro-inflammatory mediators. Although NSAIDs are essential for treating conditions such as headaches, menstrual pain, osteoarthritis, and rheumatoid arthritis, their use is associated with risks including gastrointestinal (GI) ulcers, renal impairment, cardiovascular complications, bleeding disorders, allergic reactions, and rare liver toxicity.

NSAID Use and Safety Issues in Malaysia

NSAIDs are commonly used in Malaysia and were ranked the eighth most utilized medication group in 2007. Adverse drug reactions (ADRs) related to NSAIDs are frequently reported. NPRA data shows an increase from 1,575 ADR cases in 2017 to 4,411 cases in 2021, with skin, eye, respiratory, general, and GI disorders being the most common. These rising numbers indicate persistent safety concerns and emphasize the need for responsible NSAID use.

A literature review covering studies from 2017–2025 examined NSAID utilization, prescribing patterns, safety concerns, public and healthcare worker knowledge, and evidence-based recommendations.

Key Findings from Malaysian Studies

1. Utilization and Prescribing Patterns

Studies show:

• Diclofenac, mefenamic acid, ibuprofen, and ketoprofen are among the most commonly used NSAIDs.

• High-risk prescribing practices remain prevalent, with inadequate gastroprotection and use in patients with cardiovascular conditions.

• Trends show increased analgesic prescribing overall, including NSAIDs, tramadol, and limited opioid use.

• Pediatric NSAID prescribing is increasing, with ibuprofen being the most common.

• Post-operative orthopedic settings show varied NSAID use patterns, with some drugs exceeding WHO DDD benchmarks.

2. Knowledge, Attitudes, and Practices

Research indicates:

• Many Malaysians have poor or moderate knowledge about NSAID risks.

• Over half of university students and community pharmacy patients show inadequate understanding of side effects and interactions.

• Healthcare workers, including doctors and pharmacists, show low knowledge regarding NSAID hypersensitivity, with dermatologists performing best.

3. Safety Concerns and Adverse Effects

Local clinical studies highlight notable rates of NSAID-related GI complications:

• Long-term NSAID use results in a 13.2% GI adverse event risk in arthritis patients.

• Another study found 7.2% of long-term NSAID users experienced upper GI bleeding, with older age and diclofenac use being significant predictors.

Opportunities for Improvement

Evidence suggests substantial room for improving NSAID safety in Malaysia through:

• Targeted patient education on proper use and risks.

• Enhanced prescriber training, particularly on hypersensitivity and high-risk groups.

• Greater emphasis on gastroprotection, risk assessment, and monitoring.

• Consideration of safer alternatives (e.g., COX-2 inhibitors when appropriate, non-pharmacological pain management).

Conclusion

This review highlights that NSAIDs are widely utilized in Malaysia, emphasizing the importance of rational prescribing and monitoring. Studies on utilization and prescribing patterns indicate their extensive use, while research on knowledge, attitude, practice, and perception reveals the need for greater awareness among healthcare professionals and patients. Persistent safety concerns and adverse effects underline the importance of pharmacovigilance and patient education. Evidence for improvement and alternatives supports pharmacist-led education, adherence to clinical guidelines, and promoting safer formulations such as topical NSAIDs to enhance therapeutic outcomes and ensure responsible NSAID use in Malaysian healthcare.

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Copyright © 2025 Mohamed Adel M Algeriani, Hazrina Hamid. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.