Is a short course of naproxen (nonsteroidal anti-inflammatory drug (NSAID)) reasonable for a patient with two coronary artery stents and normal blood pressure to relieve severe foot pain?

Naproxen Use in Patients with Coronary Stents

A short course of naproxen is reasonable for severe foot pain in a patient with two coronary stents and normal blood pressure, but only after attempting safer first-line analgesics and using the lowest effective dose for the shortest duration possible. 1

Risk Stratification for This Patient

The presence of coronary stents indicates established cardiovascular disease, which places this patient in a higher-risk category for NSAID-related cardiovascular complications. 1, 2 The FDA explicitly warns that NSAIDs may cause increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, with risk amplified in patients with cardiovascular disease. 2 Studies demonstrate hazard ratios of 1.50-2.80 for death in post-MI patients using NSAIDs. 3

However, normal blood pressure is a favorable factor, as NSAIDs can elevate blood pressure and reduce the effectiveness of antihypertensive medications through sodium retention. 3

Mandatory Stepped-Care Approach Before Naproxen

Before prescribing naproxen, you must attempt first-line analgesics: 1

• Acetaminophen up to 4g/day (first choice - no cardiovascular or renal risks) 1, 3
• Non-acetylated salicylates (e.g., salsalate) 1
• Tramadol 37.5-100 mg every 6 hours 3
• Small doses of narcotics if other options fail 1

Only if these provide insufficient pain relief should naproxen be considered. 1

Why Naproxen Over Other NSAIDs

If an NSAID is necessary, naproxen is the preferred choice among non-selective NSAIDs for patients with cardiovascular disease. 1, 3 A large retrospective cohort study of 48,566 patients recently hospitalized for serious coronary events found that naproxen users had the lowest adjusted rates of serious coronary heart disease (incidence rate ratio 0.88,95% CI 0.66-1.17) compared to other NSAIDs. 4

In contrast, diclofenac showed a 1.86-fold increased risk and ibuprofen a 1.67-fold increased risk of serious coronary events in the short term. 4 Importantly, naproxen risk did not increase with doses ≥1000 mg/day. 4

Specific Dosing Recommendations

Use the lowest effective dose for the shortest possible time: 1, 3

• Start with 220-440 mg twice daily (not to exceed 660 mg/day for over-the-counter use) 3
• Limit duration to 3-7 days maximum for acute pain 3
• Most documented cardiovascular adverse events occur with chronic use, not short courses 3

Critical Contraindications and Precautions

Absolute contraindications in this patient: 2

• Recent or planned coronary artery bypass graft (CABG) surgery 2
• Active gastrointestinal bleeding or history of peptic ulcer disease 2
• Severe renal impairment (creatinine clearance <30 mL/min) 3, 5

Relative contraindications requiring extreme caution: 1

• Concurrent anticoagulation (warfarin, heparin, DOACs) - increases bleeding risk 3-6 fold 5
• Concurrent aspirin therapy - do NOT use ibuprofen as it blocks aspirin's antiplatelet effects, but naproxen is acceptable 1
• Heart failure - NSAIDs can precipitate decompensation 1

Mandatory Monitoring Parameters

Before prescribing: 3, 5

• Verify baseline renal function (creatinine, eGFR) 3
• Confirm blood pressure is controlled 3
• Review all current medications for drug interactions 3

During treatment (if extending beyond 3 days): 3

• Monitor blood pressure 3
• Assess for signs of fluid retention or heart failure 3
• Monitor renal function if risk factors present 5

Gastrointestinal Protection

Consider proton pump inhibitor (PPI) co-prescription if: 1

• History of gastrointestinal bleeding 1
• Age >65 years 1
• Concurrent antiplatelet therapy (aspirin, clopidogrel) 1
• Concurrent anticoagulation 1

Common Pitfalls to Avoid

Do not combine multiple NSAIDs - this provides no additional benefit but significantly amplifies adverse effects. 5 If naproxen is insufficient, add acetaminophen rather than another NSAID. 5

Do not prescribe NSAIDs with increasing COX-2 selectivity (celecoxib, meloxicam) unless non-selective NSAIDs fail, as these carry higher cardiovascular risk. 1, 6

Do not continue naproxen chronically - if pain persists beyond 7 days, reassess the underlying cause and consider alternative pain management strategies. 1

When to Avoid Naproxen Entirely

Choose alternative analgesics if: 1

• Patient has unstable angina or recent acute coronary syndrome (within 6 months) 1
• Patient has decompensated heart failure 1
• Patient requires triple antithrombotic therapy (anticoagulant + dual antiplatelet therapy) 1
• Acetaminophen or tramadol provides adequate pain relief 1, 3