What is the preferred anti-inflammatory for pleurisy?

Preferred Anti-inflammatory for Pleurisy

NSAIDs, particularly ibuprofen, are the preferred anti-inflammatory agents for pleurisy pain management. 1

Primary Treatment Recommendation

• Ibuprofen is the first-line NSAID for pleuritic pain, as it provides effective analgesia without compromising outcomes in pleural disease 2, 1
• High-dose ibuprofen (800 mg three times daily) has been specifically validated in a large randomized trial of 320 patients with pleural disease, demonstrating equivalent pain control to opiates with no adverse effects on pleural outcomes 2
• Other NSAIDs (naproxen, indomethacin) are acceptable alternatives based on availability and patient tolerance 1

Key Evidence Supporting NSAID Use

The historical concern that NSAIDs might interfere with pleural inflammation and healing has been definitively disproven:

• A 2018 European Respiratory Society randomized controlled trial demonstrated that NSAIDs do not reduce pleurodesis success rates when compared to opiates, using a rigorous non-inferiority design 2
• This finding specifically addressed the longstanding fear that anti-inflammatory effects would impair pleural healing 2
• NSAIDs are now recognized as safe and effective for pain management in all forms of pleurisy 1

Dosing Recommendations

• Ibuprofen: 800 mg orally three times daily for acute pleuritic pain 2
• Naproxen: 500 mg orally twice daily as an alternative 3
• Treatment duration should be the shortest time needed for symptom control, typically 7-10 days 3, 1

Important Clinical Considerations

NSAIDs should be used at the lowest effective dose for the shortest duration due to potential adverse effects 3:

• Gastrointestinal ulceration and bleeding risk increases with longer use, corticosteroid co-administration, anticoagulant use, alcohol consumption, older age, and poor health 3
• Cardiovascular risks (heart attack, stroke) increase with prolonged continuous use 3
• Renal function should be monitored in patients with chronic kidney disease 3

When to Avoid NSAIDs

Contraindications include 3:

• History of asthma attack, hives, or allergic reaction to aspirin or other NSAIDs
• Immediately before or after cardiac bypass surgery
• Late pregnancy (third trimester)
• Active peptic ulcer disease or recent gastrointestinal bleeding

Corticosteroids Are NOT Recommended

• Corticosteroids do not provide clinically meaningful benefit in pleurisy, even in tuberculous pleurisy where inflammation is prominent 4
• A randomized, double-blind, placebo-controlled trial of 70 patients with tuberculous pleurisy showed that prednisone (0.75 mg/kg/day for 4 weeks) provided no significant improvement in symptoms or reduction in residual pleural thickening compared to placebo 4
• The addition of corticosteroids to standard therapy neither accelerates symptom relief nor prevents long-term complications 4

Treatment Algorithm

For uncomplicated pleurisy 1:

1. Start ibuprofen 800 mg three times daily (or naproxen 500 mg twice daily)
2. Continue for 7-10 days or until symptoms resolve
3. Taper dose if prolonged treatment is needed

For pleurisy with pleural effusion 5, 6:

1. Use NSAIDs for pain control as above
2. Treat underlying cause (antibiotics for infection, drainage for significant effusions)
3. Small effusions (<10mm) typically resolve with treatment of underlying cause alone

Common Pitfalls to Avoid

• Do not withhold NSAIDs due to unfounded concerns about impairing pleural healing - this has been definitively disproven 2
• Do not use corticosteroids for routine pleurisy - they provide no benefit and add unnecessary side effects 4
• Do not continue NSAIDs beyond 10 days without reassessing the underlying cause and need for continued therapy 3
• Do not use NSAIDs as monotherapy for infectious pleurisy - appropriate antibiotics and drainage are essential 5, 7