When should I exercise caution when prescribing naproxen (nonsteroidal anti-inflammatory drug) for pain management?

Cautions When Prescribing Naproxen for Pain

Naproxen should be used with caution in patients with cardiovascular disease, renal impairment, gastrointestinal risk factors, elderly patients over 60 years, and those taking certain medications that may interact with NSAIDs. 1, 2

High-Risk Patient Populations

Cardiovascular Risk

• Naproxen can increase cardiovascular risk, especially in patients with established cardiovascular disease or risk factors 1
• While naproxen has a better cardiovascular safety profile than other NSAIDs, it still carries risks and should be used cautiously in patients with heart disease 1
• Discontinue naproxen if hypertension develops or worsens, or if signs of congestive heart failure appear 1

Renal Risk

• Exercise caution in patients over 60 years, those with compromised fluid status, renal insufficiency, or taking other nephrotoxic drugs 1
• Monitor renal function in high-risk patients; discontinue if BUN or creatinine doubles 1
• Naproxen can reduce the effectiveness of diuretics and may worsen renal function when combined with ACE inhibitors or ARBs 2

Gastrointestinal Risk

• High-risk patients include those over 60 years, with history of peptic ulcer disease, significant alcohol use (≥2 drinks/day), or taking high doses for prolonged periods 1
• Consider gastroprotection with proton pump inhibitors in high-risk patients 1
• Naproxen can cause serious GI complications including bleeding, ulceration, and perforation, which can be fatal 2

Drug Interactions Requiring Caution

• Anticoagulants: Naproxen with warfarin or heparin significantly increases bleeding risk 1, 2
• Antihypertensives: May diminish the effect of ACE inhibitors, ARBs, or beta-blockers 2
• Aspirin: Concomitant administration is not generally recommended due to increased adverse effects 2
• Methotrexate: Naproxen may reduce tubular secretion of methotrexate, potentially enhancing its toxicity 2
• Lithium: Naproxen can elevate plasma lithium levels and reduce renal lithium clearance 2

Special Populations

Elderly Patients

• Elderly patients (>60 years) are at higher risk for NSAID-related adverse effects 1
• Use lower doses for shorter durations in elderly patients 1
• Elderly patients may have increased unbound plasma fraction of naproxen despite unchanged total concentration 2

Pregnancy and Breastfeeding

• Avoid naproxen in late pregnancy as it may cause premature closure of the ductus arteriosus 2
• Use caution in nursing mothers as naproxen is found in breast milk (approximately 1% of plasma concentration) 2

Recommended Approach to Pain Management

1. Begin with acetaminophen, small doses of narcotics, or nonacetylated salicylates for musculoskeletal pain 1
2. Consider naproxen only if initial therapy is insufficient 1
3. Use the lowest effective dose for the shortest possible time 1
4. Monitor high-risk patients with baseline and periodic checks of blood pressure, renal function, liver function, and for signs of GI bleeding 1

Contraindications

• History of asthma, urticaria, or allergic reactions after taking aspirin or other NSAIDs 2
• Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery 1
• Active peptic ulcer disease or history of recurrent GI bleeding 2
• Severe heart failure or severe renal impairment 1

Monitoring Recommendations

• Baseline assessment: blood pressure, BUN, creatinine, liver function tests, CBC, and fecal occult blood 1
• Repeat monitoring every 3 months to ensure lack of toxicity 1
• Watch for signs of hepatotoxicity (nausea, fatigue, lethargy, pruritus, jaundice, right upper quadrant tenderness) 2
• Monitor for signs of anaphylactoid reactions (difficulty breathing, facial swelling) 2

By following these precautions and using naproxen judiciously, clinicians can minimize risks while providing effective pain management for appropriate patients.