What is the recommended dosage and usage of Naproxen (Nonsteroidal Anti-Inflammatory Drug) for adults?

Naproxen Dosing and Usage for Adults

For adults with acute pain or inflammatory conditions, naproxen should be initiated at 500 mg followed by 250 mg every 6-8 hours (maximum 1250 mg first day, then 1000 mg/day thereafter), or 500 mg twice daily for chronic conditions, using the lowest effective dose for the shortest duration necessary. 1

Standard Dosing Regimens

Acute Pain Conditions (Primary Dysmenorrhea, Tendonitis, Bursitis)

• Initial dose: 500 mg, followed by 500 mg every 12 hours OR 250 mg every 6-8 hours 1
• Maximum first day: 1250 mg 1
• Maximum subsequent days: 1000 mg/day 1
• Onset of action: Pain relief begins within 1 hour 1

Chronic Inflammatory Conditions (Rheumatoid Arthritis, Osteoarthritis, Ankylosing Spondylitis)

• Standard dose: 250 mg, 375 mg, or 500 mg twice daily 1
• Dose adjustment: May be adjusted up or down based on clinical response; morning and evening doses need not be equal 1
• Higher dose option: Up to 1500 mg/day may be used for limited periods (up to 6 months) when higher anti-inflammatory activity is required, though this increases risk 1

Acute Gout

• Initial dose: 750 mg followed by 250 mg every 8 hours until attack subsides 1

Critical Safety Considerations and Contraindications

Cardiovascular Risk

• Naproxen is the preferred nonselective NSAID when NSAID therapy is necessary in patients with cardiovascular disease, as it appears to have lower cardiovascular risk compared to other NSAIDs 2
• However, all NSAIDs including naproxen cause 3.5 excess cardiac ischemic events per 1,000 persons compared to placebo 3
• Avoid in patients with congestive heart failure 3
• Use with caution in hypertension (mean BP increase of 5 mmHg) 3

Renal Impairment

• Contraindicated in moderate to severe renal impairment (creatinine clearance <30 mL/min) 3, 1
• Use with extreme caution when combining with ACE inhibitors or beta blockers due to additive renal effects 3

Gastrointestinal Risk

• 10-20% of patients experience dyspepsia or GI discomfort 3
• Risk of GI bleeding is age-dependent: 1 in 2,100 for adults <45 years versus 1 in 110 for adults >75 years 3
• Avoid in patients with history of NSAID-associated upper GI bleeding 3
• Combine with PPI or H2 blocker for gastroprotection in high-risk patients (elderly, history of ulcer, concurrent anticoagulation) 3

Stepped-Care Approach in Cardiovascular Patients

For patients with established cardiovascular disease requiring chronic pain management, guidelines recommend a hierarchical approach 2:

1. First-line: Acetaminophen, nonacetylated salicylates, tramadol, or small doses of narcotics 2
2. Second-line: Nonselective NSAIDs such as naproxen if first-line insufficient 2
3. Avoid: NSAIDs with increasing COX-2 selectivity when nonselective NSAIDs provide acceptable relief 2

Special Populations

Elderly Patients

• Use the lowest effective dose as unbound plasma fraction of naproxen increases with age 1
• Dose adjustment may be required when using higher doses 1
• Start at lower doses and titrate upward cautiously 3

Drug Interactions

• Avoid combining with anticoagulants: Increases GI bleeding risk 3-6 fold and INR by up to 15% 3
• Risk further increases with concurrent antiplatelet agents 3
• May interfere with cardioprotective effects of low-dose aspirin 2

Monitoring Requirements

Monitor at baseline and every 3 months: 3

• Blood pressure
• BUN and creatinine
• Liver function tests
• Complete blood count
• Fecal occult blood

Duration and Efficacy Assessment

• Use the lowest effective dose for the shortest possible time 2
• If two NSAIDs tried in succession show no efficacy, use another approach to analgesia 3
• For chronic conditions, dose may be adjusted based on clinical response; lower daily doses may suffice for long-term administration 1

Common Pitfalls to Avoid

• Do not use in patients with moderate to severe renal impairment 3, 1
• Do not combine with anticoagulants without gastroprotection and careful monitoring 3
• Do not use COX-2 selective NSAIDs when naproxen provides adequate relief in cardiovascular patients 2
• Do not exceed maximum daily doses (1250 mg first day, 1000 mg thereafter for acute pain; 1500 mg for chronic conditions only for limited periods) 1
• Do not continue therapy without regular monitoring of renal function, blood pressure, and GI symptoms 3