What is the recommended dosing for naproxen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) in adults?

Naproxen Adult Dosing Guidelines

The recommended standard dosing for naproxen in adults is 250-500 mg twice daily, with a maximum daily dose of 1500 mg for limited periods of up to 6 months. 1

Standard Dosing by Indication

Rheumatoid Arthritis, Osteoarthritis, and Ankylosing Spondylitis

• Initial dose: 250 mg, 375 mg, or 500 mg twice daily 1
• Long-term maintenance: May adjust dose up or down based on clinical response
• Maximum dose: 1500 mg/day for limited periods up to 6 months when higher anti-inflammatory activity is required 1
• Morning and evening doses do not need to be equal in size 1

Acute Pain, Primary Dysmenorrhea, Acute Tendonitis and Bursitis

• Starting dose: 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required 1
• Initial total daily dose should not exceed 1250 mg 1
• Maintenance: Total daily dose should not exceed 1000 mg 1

Acute Gout

• Starting dose: 750 mg followed by 250 mg every 8 hours until the attack has subsided 1

Special Populations

Elderly Patients

• Consider lower starting doses 1
• Although total plasma concentration remains unchanged, the unbound plasma fraction of naproxen increases in the elderly 1
• Use the lowest effective dose in elderly patients 1

Renal Impairment

• Not recommended for patients with moderate to severe renal impairment (creatinine clearance <30 mL/min) 1
• Consider lower doses in patients with mild renal impairment 1

Hepatic Impairment

• Consider lower doses in patients with hepatic impairment 1

Formulation Considerations

• Different formulations (tablets, suspension, delayed-release tablets, sodium tablets) have pharmacokinetic differences that may affect onset of action 1
• All formulations circulate in plasma as naproxen 1
• Pain relief can begin within 1 hour 1

Risk Mitigation Strategies

Gastrointestinal Risk

• The risk of GI complications increases with:
  • Age >65 years 2
  • History of ulcers
  • Concomitant use of anticoagulants (increases risk 5-6 times) 2
• Consider combining with a proton pump inhibitor for patients at high risk of GI complications 3

Cardiovascular Risk

• Naproxen appears to have a more favorable cardiovascular profile compared to other NSAIDs 3
• For patients taking aspirin, naproxen is preferred as it doesn't interfere with aspirin's cardioprotective effects 3

Common Pitfalls and Caveats

1. Duration of therapy: Limit to shortest duration possible to minimize risks of adverse effects 3

2. Avoid combination with other NSAIDs: This dramatically increases the risk of GI complications 3

3. Monitor blood pressure: Check within 1-2 weeks of starting therapy 3

4. Continuous vs. on-demand use: For conditions like ankylosing spondylitis, on-demand treatment is conditionally recommended over continuous treatment in stable patients 2

5. Bone pain management: For patients receiving CSF treatment who experience bone pain, naproxen 500 mg twice daily for 5-8 days may reduce the incidence, duration, and severity of bone pain 2

Remember that naproxen, like all NSAIDs, carries risks of gastrointestinal, cardiovascular, and renal adverse effects. Always use the lowest effective dose for the shortest duration possible to minimize these risks.