What nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for a 47-year-old female?

NSAID Selection for a 47-Year-Old Female

For a 47-year-old woman without specific contraindications, start with oral ibuprofen 400-800 mg every 6 hours or naproxen 500 mg twice daily, using the lowest effective dose for the shortest duration necessary. 1, 2

Primary NSAID Recommendations

For this age group, the following NSAIDs are appropriate first-line options:

• Ibuprofen 400-800 mg every 4-6 hours (maximum 3200 mg/day) is effective for pain and inflammation with a well-established safety profile 1, 3
• Naproxen 500 mg twice daily is the safest NSAID from a cardiovascular perspective and should be strongly considered if cardiovascular risk factors are present 4, 2
• Topical NSAIDs (diclofenac gel) should be preferred over oral formulations if pain is localized, as they provide similar efficacy with significantly reduced systemic side effects 1, 5

Critical Pre-Treatment Assessment

Before prescribing any NSAID, evaluate for the following absolute contraindications:

• Active peptic ulcer disease - NSAIDs are absolutely contraindicated 6, 5
• History of gastrointestinal bleeding - requires either avoidance or mandatory gastroprotection 1
• Uncontrolled hypertension - NSAIDs can increase blood pressure by an average of 5 mm Hg 1
• Chronic kidney disease - NSAIDs can worsen renal function 1
• Heart failure - NSAIDs should be avoided entirely 1, 2
• Pregnancy (especially third trimester) - NSAIDs are contraindicated 1, 2

Mandatory Gastroprotection Strategy

If the patient has any gastrointestinal risk factors (age >65, history of ulcer, concurrent corticosteroid use, or anticoagulant therapy), co-prescribe a proton pump inhibitor with any oral NSAID. 1

For patients with prior symptomatic ulcer but no recent bleeding:

• Use either a COX-2 selective inhibitor (celecoxib) OR a nonselective NSAID plus proton pump inhibitor 1

For patients taking low-dose aspirin for cardioprotection:

• Use a nonselective NSAID other than ibuprofen (which interferes with aspirin's antiplatelet effect) plus a proton pump inhibitor 1
• Avoid COX-2 selective inhibitors in this scenario 1

Cardiovascular Considerations

Naproxen has the lowest cardiovascular risk among NSAIDs and should be the preferred choice if cardiovascular disease or risk factors are present. 4

• All NSAIDs except naproxen increase cardiovascular risk within weeks of treatment initiation 4
• Diclofenac is as COX-2 selective as celecoxib and carries similar cardiovascular risk 4
• COX-2 selective inhibitors (celecoxib, etoricoxib) increase risk of myocardial infarction and thrombotic events 4, 7

Alternative to NSAIDs

If the patient has multiple risk factors or contraindications to NSAIDs, start with acetaminophen up to 4000 mg daily before considering NSAID therapy. 1, 6

• Acetaminophen should be optimized to full therapeutic dosing (1000 mg per dose, up to 4000 mg daily) as it demonstrates non-inferiority to NSAIDs for many musculoskeletal conditions 6
• Counsel patients to avoid all other acetaminophen-containing products including over-the-counter cold remedies 1

Specific Clinical Scenarios

For mild-to-moderate migraine headaches:

• Oral NSAIDs (ibuprofen 400-800 mg or naproxen 500 mg) are first-line options 1
• Combination analgesics containing caffeine enhance efficacy 1

For osteoarthritis pain:

• Acetaminophen is the initial conditional recommendation 1
• If acetaminophen fails, use oral NSAIDs or topical NSAIDs 1
• For patients ≥75 years, strongly prefer topical over oral NSAIDs 1

Duration and Monitoring

Use NSAIDs at the lowest effective dose for the shortest duration possible, ideally ≤2 weeks for acute conditions. 6, 5

• Avoid chronic daily use as this increases risk of rebound headaches (for migraine treatment) and cumulative toxicity 1
• Monitor blood pressure at each visit, as NSAIDs can worsen hypertension 1
• Assess for signs of gastrointestinal bleeding (black stools, hematemesis) and discontinue immediately if present 1, 2

Common Pitfalls to Avoid

• Never combine multiple NSAIDs simultaneously - this increases toxicity without improving efficacy 5
• Do not use ibuprofen with low-dose aspirin - ibuprofen interferes with aspirin's cardioprotective effects through pharmacodynamic interaction 1
• Avoid NSAIDs in patients taking anticoagulants - risk of gastrointestinal bleeding increases 3-6 fold; if unavoidable, expect INR to increase up to 15% 1
• Do not prescribe NSAIDs for non-inflammatory conditions when simple analgesics would suffice - NSAIDs have not been shown superior to acetaminophen for non-inflammatory osteoarthritis 8