Is naproxen safe for a patient with impaired renal function and hip pain?

Naproxen Safety in a Patient with Impaired Renal Function (GFR 63) and Hip Pain

Naproxen should be used with caution in this 62-year-old man with a GFR of 63 ml/min due to increased risk of further renal impairment, but it is not absolutely contraindicated at this level of renal function. 1, 2

Renal Considerations with Naproxen

• NSAIDs, including naproxen, can cause volume-dependent renal failure due to inhibition of prostaglandin production, which is particularly important in patients with existing renal impairment 1
• The FDA label for naproxen does not recommend its use in patients with moderate to severe renal impairment (creatinine clearance <30 ml/min), but your patient's GFR of 63 ml/min represents mild renal impairment 2
• Naproxen is primarily excreted by the kidneys (95% of the dose), with renal insufficiency potentially leading to accumulation of metabolites 2
• Studies have shown that naproxen can reduce glomerular filtration rate by approximately 18% in patients with impaired renal function 3

Recommendations for This Patient

• If naproxen is used, employ the lowest effective dose for the shortest duration possible to minimize renal risk 2
• Consider starting with 250mg twice daily rather than higher doses, as the FDA recommends using the lowest effective dose in patients with renal impairment 2
• Monitor renal function more frequently while on naproxen therapy, especially if treatment extends beyond a few days 1
• Be vigilant for signs of worsening renal function such as decreased urine output, edema, or increasing serum creatinine 4

Alternative Approaches to Consider

• Acetaminophen may be a safer alternative for pain management in this patient with renal impairment, though the total daily dose should be limited to 2000 mg/day 5
• Topical NSAIDs might provide localized pain relief with potentially less systemic absorption and renal effects, though safety data in renal impairment is limited 1
• If pain is severe and requires stronger medication, consult with nephrology before initiating therapy 1

Additional Precautions

• Avoid combining naproxen with other medications that may further impair renal function, such as ACE inhibitors, angiotensin receptor blockers, or diuretics 1
• The patient should maintain adequate hydration while taking naproxen to minimize renal risk 4
• Instruct the patient to report symptoms such as decreased urination, flank pain, or edema immediately 4, 6
• Acute overdose of naproxen has been associated with significant renal impairment presenting with lumbar pain and oliguria 4

Monitoring Recommendations

• Check baseline renal function before starting therapy 1
• Consider rechecking renal function within 3-7 days of initiating therapy, especially if treatment is expected to continue 1
• Monitor for signs of fluid retention, hypertension, or edema which may indicate worsening renal function 1
• Be aware that even short-term use of naproxen (4 days) has been reported to cause renal papillary necrosis in some cases 6