What is the recommended treatment approach for a patient with hand arthritis using Relafen (nabumetone)?

Relafen (Nabumetone) for Hand Arthritis

Relafen (nabumetone) should be reserved as a second-line oral NSAID for hand arthritis, used only after topical NSAIDs and acetaminophen have failed, at a starting dose of 1,000 mg once daily at bedtime, with mandatory cardiovascular and gastrointestinal risk assessment before prescribing. 1, 2, 3

Treatment Algorithm: When to Use Nabumetone

First-Line Treatments (Try These First)

• Start with topical NSAIDs (diclofenac gel or ibuprofen cream) applied 3-4 times daily to affected joints—these have superior safety profiles and are specifically recommended for hand OA affecting a few joints 1, 4, 2
• Add acetaminophen up to 4g/day as the oral analgesic of first choice (92% expert consensus) before considering any oral NSAID 1, 4, 2
• Implement non-pharmacological interventions concurrently: education on joint protection, daily range-of-motion and strengthening exercises, heat application (paraffin wax) before exercise, and splints for thumb base OA 5, 1, 4

When to Prescribe Nabumetone

• Only prescribe oral nabumetone after inadequate response to topical NSAIDs AND acetaminophen 1, 4, 2
• Starting dose: 1,000 mg once daily at bedtime (can be taken with or without food) 3
• Dose adjustment: Some patients may require 1,500-2,000 mg/day for adequate symptom relief, which can be given as a single dose or divided twice daily 3
• Patients weighing <50 kg are less likely to require doses beyond 1,000 mg 3
• Maximum studied dose: 2,000 mg/day (higher doses have not been evaluated) 3

Mandatory Pre-Treatment Risk Assessment

Cardiovascular Risk Stratification

• Assess for: history of MI, stroke, heart failure, hypertension, or established cardiovascular disease 4, 2
• If cardiovascular risk is present: Use extreme caution with nabumetone; COX-2 inhibitors are contraindicated, but nabumetone (a non-selective NSAID with preferential COX-2 inhibition) requires careful risk-benefit analysis 2, 6, 7

Gastrointestinal Risk Stratification

• Assess for: prior peptic ulcer, GI bleeding, concurrent anticoagulation, or corticosteroid use 4, 2
• If GI risk is increased: Consider adding gastroprotective agent (PPI) or selecting alternative therapy 2
• Nabumetone advantage: Lower GI toxicity compared to traditional NSAIDs due to its non-acidic prodrug structure and preferential COX-2 inhibition, with annual ulceration/bleeding rates <1% 6, 8, 7

Evidence Supporting Nabumetone Efficacy

• Nabumetone 1,000 mg/day is comparable in efficacy to naproxen 500 mg/day and aspirin 3,600 mg/day for both osteoarthritis and rheumatoid arthritis 3, 9, 8
• Clinical trials demonstrate: NNT of 3 (95% CI: 2-6) for oral NSAIDs in hand OA, with effect size of 0.40 for pain relief 5
• Long-term data: In open-label studies, 80% of patients continued treatment at 1 year, with 20% withdrawn for lack of effectiveness 3

Critical Pitfalls to Avoid

• Never start oral NSAIDs without trying topical NSAIDs first, especially in patients ≥75 years—this violates evidence-based treatment algorithms 4, 2
• Never prescribe nabumetone indefinitely without reassessment—re-evaluate necessity, efficacy, and emerging risk factors every 4-8 weeks 4, 2
• Never use the lowest dose principle as an excuse for underdosing—1,000 mg/day is the evidence-based starting dose; adjust upward if inadequate response after observing initial therapy 3
• Never overlook non-pharmacological interventions—these form the foundation and must continue even when medications are added 4
• Never ignore diarrhea as a side effect—nabumetone has a significantly higher incidence of diarrhea with lower abdominal pain compared to other NSAIDs 10

Monitoring and Duration

• Use the lowest effective dose for the shortest duration consistent with treatment goals 3
• Reassess every 4-8 weeks: efficacy, adverse effects, continued necessity, and changes in cardiovascular/GI risk factors 4, 2
• Consider intra-articular corticosteroid injection for painful inflammatory flares, particularly in thumb base (trapeziometacarpal) joint 1, 4
• Refer for surgery (interposition arthroplasty, osteotomy, or arthrodesis) if severe thumb base OA persists after 3-6 months of conservative treatment failure 1, 4