Is Naproxen (naproxen) 500 mg twice a day (BID) suitable for a 68-year-old male patient with cirrhosis (liver cirrhosis), hypertension (high blood pressure), and knee pain?

From the Guidelines

Naproxen 500 mg twice daily is not suitable for a 68-year-old male patient with cirrhosis, hypertension, and knee pain. This medication should be avoided in patients with liver cirrhosis due to the increased risk of hepatotoxicity and potential for worsening liver function, as noted in the study by 1. Additionally, naproxen and other NSAIDs can worsen hypertension, reduce the effectiveness of antihypertensive medications, and increase the risk of cardiovascular events, as highlighted in the study by 1. For this patient, acetaminophen (Tylenol) would be a safer alternative for knee pain, starting at 500-650 mg every 6 hours as needed, not exceeding 3,000 mg per day, as recommended by 1 and 1. If pain relief is inadequate, consultation with a healthcare provider is recommended to discuss other options such as topical NSAIDs, physical therapy, or joint injections. The patient should also maintain regular monitoring of blood pressure and liver function while managing pain. NSAIDs like naproxen are particularly problematic in cirrhosis patients because they can reduce renal blood flow, potentially precipitating hepatorenal syndrome, and may increase bleeding risk due to platelet dysfunction and potential esophageal varices. Some key points to consider in the management of knee pain in this patient include:

• Avoiding NSAIDs due to the risks associated with liver cirrhosis and hypertension
• Using acetaminophen as a first-line treatment for knee pain
• Monitoring blood pressure and liver function regularly
• Considering alternative treatments, such as topical NSAIDs or physical therapy, if pain relief is inadequate.

From the FDA Drug Label

Although naproxen tablets, naproxen suspension, naproxen delayed-released tablets, and naproxen sodium tablets all circulate in the plasma as naproxen, they have pharmacokinetic differences that may affect onset of action A lower dose should be considered in patients with renal or hepatic impairment or in elderly patients (see WARNINGS and PRECAUTIONS). Geriatric Patients Studies indicate that although total plasma concentration of naproxen is unchanged, the unbound plasma fraction of naproxen is increased in the elderly Caution is advised when high doses are required and some adjustment of dosage may be required in elderly patients. The recommended dose is 250 mg, 375 mg, or 500 mg twice daily

The patient has cirrhosis (liver cirrhosis), hypertension (high blood pressure), and knee pain. Considering the patient's hepatic impairment (cirrhosis) and elderly status, a lower dose of naproxen should be considered. The recommended dose for osteoarthritis is 250 mg, 375 mg, or 500 mg twice daily. However, due to the patient's hepatic impairment and age, the dose of 500 mg twice daily may be too high.

Key considerations:

• Hepatic impairment: A lower dose should be considered.
• Elderly patient: Caution is advised when high doses are required, and some adjustment of dosage may be required.
• Renal function: The patient's e-GFR is 65, which is within the normal range, but the dose should still be carefully considered.

Given these considerations, the dose of naproxen 500 mg BID may not be suitable for this patient. A lower dose, such as 250 mg or 375 mg twice daily, may be more appropriate, and the patient should be closely monitored for adverse effects 2.

From the Research

Patient Assessment

The patient is a 68-year-old male with a history of cirrhosis, hypertension, and knee pain, among other conditions. He is requesting Naproxen 500 mg twice a day (BID) for his knee pain.

Considerations for Naproxen Use

• Cirrhosis: The use of non-selective nonsteroidals like Naproxen in patients with cirrhosis is generally discouraged due to the risk of worsening renal function, blunting diuretic response, and increasing the risk of portal hypertensive and peptic ulcer bleeding 3.
• Hypertension: Naproxen can also affect blood pressure, which is a concern for patients with hypertension.
• Renal Function: The patient's renal function, as indicated by his e-GFR of 65, is mildly decreased but still within the normal range. However, the use of Naproxen could potentially worsen renal function, especially in the context of cirrhosis 4.

Alternative Options

• Acetaminophen: Remains the preferred analgesic for patients with cirrhosis, as it is safe when used at recommended doses (up to 2 g/day) 3.
• Celecoxib: Can be considered for short-term use (≤5 days) in patients with Child's A and Child's B cirrhosis, with a 50% dose reduction 3.
• Topical Agents: Topical diclofenac and lidocaine may be safe alternatives for pain management in patients with cirrhosis 3.

Efficacy and Safety of Naproxen

• Efficacy: Naproxen has been shown to be effective in treating osteoarthritis of the knee, with improvements in pain indices, tenderness, swelling, and functional capacity 5, 6.
• Safety: While Naproxen can be well-tolerated in some patients, its use in patients with cirrhosis and hypertension requires careful consideration due to the potential risks mentioned above.

Conclusion Not Provided as per Request

Instead, the information provided highlights the need for careful evaluation of the patient's condition and consideration of alternative pain management options that are safer for patients with cirrhosis and hypertension. The decision to use Naproxen should be based on a thorough assessment of the potential benefits and risks, and alternative treatments should be considered whenever possible.