What's the best non-narcotic (NN) medication to give for an elbow strain due to hyperextension?

Best Non-Narcotic Medication for Elbow Hyperextension Strain

For an acute elbow strain from hyperextension injury, acetaminophen (paracetamol) should be the first-line non-narcotic analgesic, with NSAIDs like ibuprofen or naproxen reserved as second-line options if acetaminophen provides insufficient pain relief. 1

First-Line Treatment: Acetaminophen

• Acetaminophen is the preferred initial oral analgesic for musculoskeletal pain because it provides an optimal balance between efficacy and safety compared to NSAIDs 1
• It should be used at regular intervals rather than "as needed" for optimal pain control in the acute phase 1
• Acetaminophen is safer and cheaper than NSAIDs while avoiding the cardiovascular and gastrointestinal risks associated with anti-inflammatory medications 1

Second-Line Treatment: NSAIDs

If acetaminophen provides inadequate pain relief after 24-48 hours:

• Non-selective NSAIDs such as naproxen or ibuprofen should be used at the lowest effective dose for the shortest duration 1
• For ankle sprains (similar acute soft tissue injury), oral NSAIDs demonstrated pain reduction in the short term (<14 days) with acceptable safety profiles 1
• Ibuprofen 800 mg/day or naproxen 500 mg twice daily are reasonable choices for moderate musculoskeletal pain 1

Important Caveats and Contraindications

Cardiovascular Risk Considerations

• All NSAIDs carry cardiovascular risk that increases with COX-2 selectivity, particularly in patients with established cardiovascular disease 1
• Non-selective NSAIDs like naproxen have lower cardiovascular risk compared to selective COX-2 inhibitors 1
• Avoid NSAIDs entirely in patients with significant cardiovascular disease, uncontrolled hypertension, or recent myocardial infarction 1

Gastrointestinal Risk Management

• NSAIDs should be avoided or used with extreme caution in patients with gastrointestinal risk factors (history of ulcers, age >65, concurrent anticoagulation) 1
• If NSAIDs are necessary in high-GI-risk patients, co-prescribe a proton pump inhibitor for gastroprotection 1

Renal Considerations

• Use NSAIDs cautiously in patients with chronic kidney disease or those taking medications affecting renal function 1
• Acetaminophen remains safer in patients with renal impairment 1

Topical Alternatives

For localized elbow pain, consider topical options:

• Topical NSAIDs (diclofenac gel) provide localized pain relief with reduced systemic absorption and may be preferable to oral NSAIDs in older patients or those with contraindications 1
• Topical lidocaine patches (5%) can be applied to the affected area for neuropathic-type pain if present 1

What NOT to Use

• Avoid selective COX-2 inhibitors (celecoxib, rofecoxib) for routine musculoskeletal injuries due to increased cardiovascular risk without superior efficacy 1
• Opioid analgesics should be avoided for simple musculoskeletal strains as they provide no superior benefit and carry significant risks of side effects and dependence 1

Practical Treatment Algorithm

1. Start with acetaminophen 650-1000 mg every 6-8 hours (maximum 4000 mg/24 hours) 1
2. If inadequate relief after 24-48 hours, add or switch to ibuprofen 400-800 mg three times daily or naproxen 500 mg twice daily 1
3. Use NSAIDs for the shortest duration possible (typically 5-7 days for acute strain) 1
4. Consider topical NSAIDs as an alternative to oral NSAIDs in patients >65 years or with GI/CV risk factors 1
5. Reassess pain at 48-72 hours; if not improving, consider alternative diagnoses or need for imaging 1