What is the recommended dose of naproxen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) for an elderly patient with osteoarthritis (OA) who has tried acetaminophen (Tylenol) and physiotherapy?

Naproxen Dosing for Elderly Patients with Osteoarthritis

For an elderly patient with osteoarthritis who has failed acetaminophen and physiotherapy, start naproxen at 440 mg daily (220 mg twice daily) rather than standard adult doses, use the lowest effective dose for the shortest duration possible, and strongly consider adding a proton pump inhibitor for gastroprotection. 1

Age-Specific Dosing Considerations

Elderly patients require dose reduction due to increased risk of NSAID toxicity. The evidence demonstrates that:

• For patients ≥65 years, the recommended naproxen sodium dose is 440 mg/day (equivalent to 400 mg naproxen base), which translates to 220 mg twice daily. 2
• Patients under 65 years can receive 660 mg/day naproxen sodium (600 mg naproxen base), but your patient exceeds this age threshold. 2
• The FDA label explicitly warns that elderly patients are particularly sensitive to NSAID adverse effects and may tolerate GI bleeding less well when it occurs. 3
• Dose adjustment is required in elderly patients, and the lowest effective dose should be used. 3

Critical Safety Framework for Elderly NSAID Use

NSAIDs should not be used in high doses for long periods in elderly patients due to elevated risk of GI, renal, and cardiovascular toxicity. 1

Mandatory Risk Assessment Before Prescribing

Before initiating naproxen, evaluate for absolute and relative contraindications:

• Chronic kidney disease stage IV or V (eGFR <30 mL/min) is an absolute contraindication to oral NSAIDs. 1
• For CKD stage III (eGFR 30-59 mL/min), carefully weigh benefits versus risks on an individual basis. 1
• History of gastroduodenal ulcers or GI bleeding requires either a COX-2 selective inhibitor OR a nonselective NSAID combined with a proton pump inhibitor. 1
• Congestive heart failure, hypertension, and hepatic disease increase drug-disease interaction risks. 1

Gastroprotection Strategy

Add a proton pump inhibitor whenever prescribing NSAIDs for chronic management of osteoarthritis in elderly patients. 1

• If the patient has had an upper GI bleed within the past year, use a COX-2 selective inhibitor PLUS a proton pump inhibitor (not naproxen alone). 1
• If taking low-dose aspirin (≤325 mg/day) for cardioprotection, use a nonselective NSAID other than ibuprofen combined with a proton pump inhibitor, as ibuprofen interferes with aspirin's cardioprotective effects. 1
• Adding a proton pump inhibitor to any NSAID is cost-effective and reduces symptomatic or complicated upper GI events. 1

Practical Dosing Regimen

Start with naproxen 220 mg (or naproxen sodium 220 mg) twice daily with food. 2

• The elimination half-life of naproxen is 12-17 hours, and steady-state levels are reached in 4-5 days. 3
• Peak plasma levels occur 2-4 hours after administration. 3
• Twice-daily dosing provides consistent analgesic coverage. 3

Monitoring Requirements

Obtain detailed medication history including all OTC medications before prescribing, as drug-drug interactions are common. 1

• Monitor blood pressure, renal function (serum creatinine/eGFR), and liver function if prolonged use is anticipated. 3
• Naproxen is >99% protein-bound, and the unbound fraction increases in elderly patients (0.12-0.19% versus 0.05-0.075% in younger patients), potentially increasing adverse event rates. 3
• Approximately 95% of naproxen is excreted renally, and metabolites may accumulate in renal impairment. 3

Expected Efficacy and Treatment Duration

Naproxen 1000 mg/day (500 mg twice daily) has demonstrated superior efficacy to acetaminophen for moderate-to-severe OA pain, but your elderly patient should start at lower doses. 4

• In comparative trials, naproxen 750-1000 mg/day showed similar efficacy to other NSAIDs and was generally well-tolerated for up to 12 months. 5, 6
• However, use the lowest effective dose for the shortest duration necessary. 1
• Reassess after 1-2 weeks; if inadequate response at 440 mg/day, cautiously increase to 500 mg twice daily (1000 mg/day) only if well-tolerated and no contraindications emerge. 7

Alternative Approaches if Naproxen is Contraindicated

If this patient has contraindications to oral NSAIDs:

• Topical NSAIDs are strongly recommended for patients ≥75 years instead of oral NSAIDs. 1
• Intraarticular corticosteroid injections are strongly recommended for moderate-to-severe knee or hip OA pain. 1
• Tramadol or duloxetine are conditional recommendations if NSAIDs cannot be used. 1

Critical Pitfalls to Avoid

Never combine naproxen with other NSAIDs—patients often fail to disclose OTC NSAID use (ibuprofen, aspirin >325 mg/day). 1

• Explicitly counsel the patient to avoid all other NSAIDs including OTC products. 1
• Adverse events with nonselective NSAIDs are more frequent than with any other drug class. 1
• Most spontaneous reports of fatal GI events occur in the geriatric population. 3