What nonsteroidal anti-inflammatory drug (NSAID) should I prescribe?

NSAID Selection for Pain Management

For most patients requiring an NSAID, naproxen is the preferred first-line option due to its favorable cardiovascular safety profile, longer duration of action, and established efficacy. 1

Patient Risk Assessment Before NSAID Selection

When selecting an NSAID, consider these key risk factors:

• Cardiovascular risk: Assess for hypertension, history of heart disease, stroke risk
• Gastrointestinal risk: Check for history of ulcers, GI bleeding, age >65
• Renal function: Evaluate baseline kidney function
• Medication interactions: Particularly anticoagulants, aspirin, ACE inhibitors
• Age: Elderly patients have increased risk of adverse effects

NSAID Selection Algorithm

First-line options:

• Naproxen (500mg BID): Best overall safety profile for cardiovascular risk patients 1
• Ibuprofen (400-800mg TID): Good option for short-term use with fewer comorbidities 1

For patients with specific risk factors:

1. Cardiovascular disease/risk:

   • Naproxen is preferred (least cardiovascular risk)
   • Avoid COX-2 inhibitors and high-dose NSAIDs
   • If patient is on low-dose aspirin, avoid ibuprofen (interferes with aspirin's cardioprotective effect) 1

2. GI risk factors:

   • Add proton pump inhibitor (PPI) to non-selective NSAID
   • OR use celecoxib (Celebrex) with PPI for highest risk patients 1
   • Avoid NSAIDs entirely in patients with active ulcers

3. Renal impairment:

   • Avoid all NSAIDs in severe renal disease
   • Use lowest effective dose for shortest duration in mild-moderate impairment
   • Monitor renal function within 1-2 weeks of starting therapy 1

4. Elderly patients (>65 years):

   • Use lowest effective dose for shortest duration
   • Add PPI for gastroprotection
   • Monitor blood pressure and renal function closely 1

Dosing Recommendations

• Naproxen: 500mg twice daily (maximum 1500mg/day)
• Ibuprofen: 400-800mg three times daily (maximum 2400mg/day)
• Celecoxib: 100-200mg once or twice daily (for high GI risk patients)

Important Precautions

• Duration: Use the lowest effective dose for the shortest duration possible 2
• Monitoring: Check blood pressure within 1-2 weeks of starting therapy 1
• Gastroprotection: Add PPI for patients >65 years, history of ulcers, or concomitant use of anticoagulants/corticosteroids 1
• Aspirin interaction: If patient takes low-dose aspirin, avoid ibuprofen or administer ibuprofen at least 30 minutes after or 8 hours before aspirin 1

Common Pitfalls to Avoid

• Combining multiple NSAIDs: Increases risk without additional benefit
• Prolonged use without monitoring: Check renal function and blood pressure periodically
• Inadequate gastroprotection: High-risk patients need PPI co-therapy
• Ignoring drug interactions: Particularly with anticoagulants, which dramatically increase bleeding risk
• Overlooking cardiovascular risk: All NSAIDs except aspirin may increase cardiovascular events

Remember that all NSAIDs carry risks, and the goal should be to use the lowest effective dose for the shortest duration necessary to control symptoms while monitoring for adverse effects.