What is a suitable prescription for treating inflammation?

Prescription for Inflammation

For acute inflammation without significant inflammatory component, prescribe ibuprofen 400-1200 mg daily in divided doses; for chronic inflammatory conditions requiring sustained anti-inflammatory effect, prescribe meloxicam 7.5-15 mg daily or naproxen 500-1000 mg daily. 1

First-Line Treatment Algorithm

For Acute, Non-Inflammatory Pain

• Start with ibuprofen 400 mg three times daily (1200 mg/day total) as it provides superior gastrointestinal safety and cost-effectiveness at these doses 1
• Ibuprofen at doses of 1200 mg/day has a good safety profile comparable to acetaminophen 2
• Use for the shortest duration necessary, ideally less than 14 days 3
• At full anti-inflammatory doses (2400 mg/day), ibuprofen carries GI bleeding risk comparable to other NSAIDs, so avoid prolonged use at maximum doses 4

For Chronic Inflammatory Conditions (Osteoarthritis, Rheumatoid Arthritis)

• Consider meloxicam 7.5-15 mg once daily for sustained anti-inflammatory effect, particularly in patients at moderate-to-high GI risk 1
• Alternatively, naproxen 500 mg twice daily has the most favorable cardiovascular profile among NSAIDs requiring anti-inflammatory effects 1
• NSAIDs with longer half-lives like naproxen are preferred for chronic conditions 4

Gastrointestinal Risk Stratification and Gastroprotection

Low GI Risk Patients

• Use ibuprofen 400-1200 mg daily without gastroprotection 1
• Low risk defined as: no history of GI bleeding, age <60 years, no concurrent corticosteroid or anticoagulant use 4, 5

Moderate-to-High GI Risk Patients

• Prescribe either: non-selective NSAID (ibuprofen) plus proton pump inhibitor (PPI), OR meloxicam alone 1
• For chronic inflammatory conditions in high-risk patients, meloxicam alone is preferred 1
• High risk factors include: previous GI bleeding, age >60 years, concurrent corticosteroids or anticoagulants, longer duration of use, smoking, alcohol use 4, 5
• H2-receptor antagonists have limited benefit and are inferior to PPIs for gastroprotection 4

Critical Pitfall

• Adding low-dose aspirin to meloxicam increases GI complication risk 2- to 5-fold and negates meloxicam's safety advantage 1
• In patients requiring aspirin, consider ibuprofen plus PPI instead 1

Cardiovascular Considerations

Patients with Cardiovascular Disease or Risk Factors

• Use naproxen 500 mg twice daily as it has the most favorable cardiovascular profile among NSAIDs 1
• Both ibuprofen and meloxicam require caution in patients with cardiovascular disease 1
• All NSAIDs can increase risk of myocardial infarction, heart failure exacerbation, and hypertension 6, 7

Patients on Low-Dose Aspirin

• Instruct patients to take ibuprofen ≥30 minutes after aspirin or ≥8 hours before aspirin to avoid interference with aspirin's antiplatelet effect 1
• This timing prevents ibuprofen from blocking aspirin's irreversible COX-1 inhibition 1

Specific Prescription Examples

Example 1: Acute Ankle Sprain (Low GI Risk, No CV Risk)

Ibuprofen 400 mg
Take 1 tablet by mouth three times daily with food
Dispense: 42 tablets
Duration: 14 days maximum

Example 2: Chronic Osteoarthritis (Moderate GI Risk, No CV Risk)

Meloxicam 15 mg
Take 1 tablet by mouth once daily
Dispense: 30 tablets
Refills: 2 (with required 3-month monitoring)

Example 3: Rheumatoid Arthritis (High GI Risk, CV Risk Present)

Naproxen 500 mg
Take 1 tablet by mouth twice daily with food
PLUS
Omeprazole 20 mg
Take 1 capsule by mouth once daily before breakfast
Dispense: 60 tablets naproxen, 30 capsules omeprazole
Refills: 2 (with required 3-month monitoring)

Mandatory Monitoring for Chronic NSAID Use

Baseline Assessment

• Blood pressure, BUN, creatinine, liver function tests, CBC, screen for iron-deficiency anemia 1

Every 3 Months

• Blood pressure, BUN, creatinine, liver function studies, CBC, fecal occult blood 1

Discontinuation Criteria

• Stop NSAIDs immediately if: BUN or creatinine doubles, hypertension develops or worsens, or liver enzymes increase >3× upper limit of normal 1
• NSAIDs can cause renal failure, sodium retention, hypertension, and heart failure exacerbation 6, 7

Special Populations

Elderly Patients (≥60 Years)

• Use the lowest effective dose for the shortest duration 1
• Regular acetaminophen (up to 4g daily) is safer than NSAIDs for musculoskeletal pain in elderly 1
• Higher risk of GI bleeding, renal impairment, and cardiovascular events 4, 5

Patients with Renal Impairment

• Avoid NSAIDs entirely in severe chronic kidney disease 1
• Meloxicam showed no evidence of drug accumulation in moderate renal failure, but still requires caution 1

Critical Contraindications

Do not prescribe NSAIDs if:

• History of asthma attack, hives, or allergic reaction with aspirin or any NSAID 5
• Perioperative period for coronary artery bypass graft surgery 5
• Late pregnancy (third trimester) 5
• Active GI bleeding or peptic ulcer disease 4
• Severe renal impairment 1

Patient Counseling Points

• Take with food to minimize GI upset 5
• Stop immediately and seek emergency care if: chest pain, shortness of breath, weakness, slurred speech, black tarry stools, vomiting blood 5
• Avoid alcohol as it increases GI bleeding risk 4, 5
• Do not combine with other NSAIDs including over-the-counter products 8, 9
• Review need for NSAID therapy at least every 6 months and consider "as needed" dosing rather than scheduled 4

Cost-Effectiveness Considerations

• Ibuprofen remains the most cost-effective NSAID at 3-4 times cheaper than diclofenac or naproxen 4
• No evidence supports use of modified-release preparations over immediate-release formulations 4
• For temporary problems (toothache, headache), the expense of COX-2 selective drugs does not justify their use 4