What is a safe dose of naproxen (nonsteroidal anti-inflammatory drug (NSAID)) for a generally healthy 60-year-old male with sciatica?

Naproxen Dosing for Sciatica in a 60-Year-Old Male

For a generally healthy 60-year-old male with sciatica, prescribe naproxen 500 mg twice daily (every 12 hours) for 10 days, with careful monitoring for gastrointestinal, renal, and cardiovascular toxicity. 1, 2, 3

Standard Dosing Regimen

• Start with naproxen 500 mg orally twice daily (every 12 hours) for acute sciatica pain. 1, 2
• The maximum daily dose should not exceed 1000 mg for routine use in this age group. 1, 2
• Treatment duration should be limited to 10 days for acute sciatica, as this is the evidence-based duration for NSAID therapy in this condition. 3
• If pain persists beyond 2-4 weeks, reassess the diagnosis and consider alternative or multimodal approaches rather than continuing naproxen indefinitely. 1

Critical Age-Related Considerations

Your patient's age of 60 years places him at significantly increased risk for NSAID-related complications, requiring heightened vigilance. 4, 1

Gastrointestinal Risk Factors

• Age ≥60 years is an independent risk factor for GI toxicity, including peptic ulcer disease and gastrointestinal bleeding. 4
• Consider adding a proton pump inhibitor for gastroprotection, especially if the patient has any history of peptic ulcer disease, uses alcohol (≥2 drinks daily), or takes anticoagulants or antiplatelet agents. 4, 1
• The one-year risk of serious GI bleeding increases substantially with age, reaching 1 in 110 in adults over 75 years. 5

Renal Risk Factors

• Age ≥60 years increases risk of renal toxicity, particularly with compromised fluid status or concurrent nephrotoxic medications. 4
• Ensure adequate hydration during treatment. 4

Cardiovascular Risk Factors

• Use naproxen with extreme caution if the patient has any history of cardiovascular disease, hypertension, or heart failure. 4, 1
• NSAIDs can worsen hypertension and increase risk of cardiac ischemic events. 1

Mandatory Baseline Assessment

Before prescribing naproxen, obtain:

• Blood pressure measurement 4, 1
• BUN and creatinine (to assess renal function) 4, 1
• Liver function tests (alkaline phosphatase, LDH, SGOT, SGPT) 4
• Complete blood count (CBC) 4, 1
• Fecal occult blood test 4, 1

Absolute Contraindications to Screen For

• Active peptic ulcer disease or history of gastrointestinal bleeding 5
• Moderate to severe renal impairment (creatinine clearance <30 mL/min) 2
• Current use of anticoagulants (warfarin, heparin, DOACs) - significantly increases bleeding risk 4, 1
• Aspirin-induced asthma or NSAID hypersensitivity 5
• Recent coronary artery bypass graft surgery 5

Immediate Discontinuation Criteria

Stop naproxen immediately if any of the following occur:

• BUN or creatinine doubles from baseline 4, 1
• Liver function tests increase to ≥3 times upper limit of normal 4, 1
• Development or worsening of hypertension 4, 1
• Any signs of gastrointestinal bleeding (black stools, hematemesis, severe abdominal pain) 4, 1
• Gastric upset or nausea that persists despite supportive measures 4

Monitoring During Treatment

• For short-term use (10 days), daily patient self-monitoring for side effects is appropriate. 3
• If treatment extends beyond 2-4 weeks, repeat laboratory monitoring (BP, BUN, creatinine, LFTs, CBC, fecal occult blood) every 3 months. 4, 1

Alternative Approaches if Naproxen Fails or Is Contraindicated

• Acetaminophen up to 3000 mg daily is a safer alternative in high-risk patients, though potentially less effective for inflammatory pain. 1, 5
• Consider topical NSAIDs to minimize systemic exposure for localized pain. 1, 5
• If two different NSAIDs fail sequentially, switch to an alternative analgesic approach rather than trying additional NSAIDs. 4, 1
• Opioid analgesics are safe and effective alternatives when NSAIDs are contraindicated. 4

Important Drug Interactions

• If the patient takes low-dose aspirin for cardioprotection, naproxen should be taken at least 30 minutes AFTER immediate-release aspirin or at least 8 hours BEFORE aspirin to avoid interfering with aspirin's antiplatelet effect. 5
• Never combine naproxen with other NSAIDs (including ibuprofen, ketorolac) - toxicities are additive without additional analgesic benefit. 6
• Check for "hidden" NSAIDs in combination over-the-counter medications. 5

Practical Prescribing Instructions

• Use the lowest effective dose for the shortest duration consistent with treatment goals. 5, 2
• Naproxen 500 mg tablets should be taken with food to minimize GI upset. 2
• The morning and evening doses do not need to be equal in size. 2
• Onset of pain relief typically begins within 1 hour. 2
• Provide clear written instructions about discontinuation criteria and when to seek immediate medical attention. 4