What are the guidelines for using naproxen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) in elderly patients?

Naproxen Use in Elderly Patients

Naproxen should be used rarely and with extreme caution in elderly patients, reserved only for highly selected individuals after safer therapies have failed, and always co-prescribed with a proton pump inhibitor for gastrointestinal protection. 1

Patient Selection Criteria

Naproxen may only be considered when ALL of the following conditions are met:

• Safer therapies (acetaminophen, topical NSAIDs, opioids) have failed 1
• Evidence of continuing therapeutic goals not met with alternative agents 1
• No absolute contraindications present (see below) 1

Absolute Contraindications

Never prescribe naproxen to elderly patients with:

• Active peptic ulcer disease 1
• Chronic kidney disease or creatinine clearance <30 mL/min 1, 2
• Heart failure 1

Relative Contraindications Requiring Extreme Caution

Exercise particular caution and consider alternative agents in patients with:

• Hypertension 1
• History of peptic ulcer disease or Helicobacter pylori infection 1
• Concomitant use of corticosteroids or SSRIs 1
• Concurrent aspirin therapy for cardioprophylaxis 1
• Renal impairment (even mild) 1
• Cardiovascular disease 1
• Intravascularly depleted states 1

Critical Evidence on NSAID Risks in the Elderly

NSAIDs were implicated in 23.5% of hospitalizations due to adverse drug reactions in older adults, which alone mandates extreme caution with all such agents 1. The gastrointestinal toxicity of NSAIDs increases in both frequency and severity with age 1. Naproxen specifically carries one of the highest GI toxicity profiles among NSAIDs, despite being safer for the cardiovascular system 3.

Dosing Adjustments for Elderly Patients

When naproxen is deemed absolutely necessary:

• Start at the lowest possible dose 2
• The unbound plasma fraction of naproxen is significantly increased in elderly patients despite unchanged total plasma concentration 2, 4, 5
• Clearance of unbound drug is reduced by approximately 60% in elderly patients (281 L/h vs 713 L/h in young patients) 4
• Free naproxen concentrations are 57% higher in elderly patients (141 ng/mL vs 89.8 ng/mL) 5
• Consider starting with 250 mg twice daily rather than standard doses 2, 6
• Titrate upward only if absolutely necessary based on clinical response 2

Mandatory Co-Therapy for Gastrointestinal Protection

All elderly patients taking naproxen must receive concurrent proton pump inhibitor (PPI) or misoprostol for gastrointestinal protection 1. This is a strong recommendation with high-quality evidence 1. The protection afforded is not complete, but significantly reduces risk of upper GI complications 1.

Drug Interactions Requiring Special Attention

• Do not use ibuprofen concurrently in patients taking aspirin for cardioprophylaxis 1
• Never prescribe more than one NSAID simultaneously 1
• Monitor closely in patients on ACE inhibitors, diuretics, or antiplatelets due to drug interactions 1
• Naproxen may negate the antiplatelet effect of aspirin 3

Monitoring Requirements

Routinely assess all elderly patients on naproxen for:

• Gastrointestinal toxicity (bleeding, ulceration) 1
• Renal function deterioration 1
• Blood pressure elevation 1
• Heart failure exacerbation 1
• Drug-drug and drug-disease interactions 1

Preferred Alternatives in Elderly Patients

The evidence strongly supports prioritizing these alternatives before considering naproxen:

• Acetaminophen up to 4 grams daily as first-line therapy for musculoskeletal pain 1, 7, 8
• Topical NSAIDs (diclofenac) for localized pain, which avoid systemic adverse effects 1, 8
• Opioids for moderate to severe pain when acetaminophen fails 1
• Regional anesthetic techniques (nerve blocks) for specific pain syndromes 7, 8, 9

Common Pitfalls to Avoid

• Do not assume standard adult dosing is appropriate—elderly patients have significantly altered pharmacokinetics requiring dose reduction 2, 4, 5
• Do not prescribe naproxen without concurrent PPI—this is a mandatory co-therapy 1
• Do not overlook "hidden" drug interactions—particularly with aspirin, ACE inhibitors, and diuretics 1
• Do not continue therapy without ongoing reassessment—risks and complications must be monitored continuously 1
• Do not use in trauma settings—NSAIDs are usually not recommended for elderly trauma patients, particularly those with hip fractures 1

Duration of Therapy

Use naproxen for the shortest duration possible consistent with treatment goals 2. The gastrointestinal toxicity is both dose-related and time-dependent 1. Long-term use substantially increases risk of serious complications including hemorrhage and perforation, which elderly patients tolerate poorly 2.