Naproxen or Ibuprofen for Elbow Bursitis
For acute olecranon bursitis, either naproxen or ibuprofen is appropriate as first-line NSAID therapy, with no clear superiority of one over the other; choose based on dosing convenience and patient preference, using full anti-inflammatory doses for 1-2 weeks. 1, 2, 3
Initial Treatment Approach
Conservative management with NSAIDs is the cornerstone of first-line therapy for non-septic olecranon bursitis. 3, 4, 5 The evidence supports that NSAIDs hasten symptomatic improvement when combined with rest, ice, compression, and elevation. 4, 6
NSAID Selection and Dosing
Both naproxen and ibuprofen are equally effective options for treating acute inflammatory bursitis, as no head-to-head trials demonstrate superiority of one over the other for this indication. 1
For naproxen: Use the FDA-approved anti-inflammatory dose of 500 mg twice daily (or 250 mg every 6-8 hours for milder cases). 1 This provides longer dosing intervals and may improve adherence. 1
For ibuprofen: Use full anti-inflammatory doses of 600-800 mg three times daily. 1, 2 The 2012 ACR gout guidelines (which explicitly state that bursal inflammation should follow comparable management to acute arthritis) recommend full anti-inflammatory dosing. 1
Continue the NSAID at full dose until the acute inflammation completely resolves, typically 1-2 weeks, then discontinue. 1, 2 Do not taper unless the patient has multiple comorbidities requiring dose adjustment. 1
Critical Pre-Treatment Assessment
Before prescribing either NSAID, you must evaluate:
Cardiovascular risk factors: History of heart disease, hypertension, heart failure, or recent MI. 1 Even short-term NSAID use carries cardiovascular risk, particularly at higher doses. 2
Gastrointestinal risk factors: Age >60 years, history of peptic ulcer disease, concurrent anticoagulant or corticosteroid use. 1, 2, 7
Renal function: Baseline creatinine clearance assessment is mandatory, as NSAIDs can cause fluid retention and renal toxicity. 1, 7
Gastroprotection Strategy
Add a proton pump inhibitor (PPI) if GI risk factors are present (age >65, prior GI bleeding, concurrent aspirin/anticoagulants, or corticosteroids). 2, 7 This applies to all oral NSAIDs regardless of COX-2 selectivity. 7
For patients with established cardiovascular disease or multiple CV risk factors, consider using naproxen over other NSAIDs, as observational data suggest it may have a relatively lower thrombotic risk profile. 1 However, adding low-dose aspirin may not provide sufficient protection against thrombotic events. 1
Stepped-Care Approach for High-Risk Patients
If the patient has contraindications to both naproxen and ibuprofen (e.g., active peptic ulcer, severe renal impairment, recent MI):
First alternative: Acetaminophen up to 3-4 g daily (limit to 3 g in elderly) plus compression bandaging. 1, 8, 6 A randomized trial showed compression with NSAIDs achieved 83% resolution by 4 weeks. 6
Second alternative: Topical NSAIDs (diclofenac gel) applied to the olecranon area, which have minimal systemic absorption and substantially lower GI/renal/CV risk. 8
Third alternative: Aspiration with or without intrabursal corticosteroid injection for refractory cases. 4, 9, 6 Steroid injection after aspiration achieves the earliest resolution (median 2.3 weeks vs. 3.1-3.2 weeks for other treatments). 6
Common Pitfalls to Avoid
Do not combine naproxen and ibuprofen or use with other NSAIDs concurrently, as patients often fail to disclose over-the-counter NSAID use. 2, 7
Do not exceed maximum daily doses: Naproxen 1500 mg/day; ibuprofen 2400 mg/day. 1
Do not prescribe NSAIDs without assessing CV, renal, and GI risk factors first. 7
Do not use NSAIDs for prolonged periods (>2 weeks) without re-evaluation, as the bursitis should resolve within this timeframe. 2, 3
Longer symptom duration before treatment is the only factor associated with treatment failure by 4 weeks (failed cases: 6 weeks of symptoms vs. successful cases: 4 weeks). 6 Early treatment is therefore critical. 1
When Conservative Treatment Fails
If substantial fluid reaccumulates or symptoms persist beyond 4 weeks despite appropriate NSAID therapy, consider aspiration or aspiration with steroid injection. 6, 5
Surgical bursectomy should be reserved only for chronic, recurrent, or refractory cases that fail conservative management. 9, 5 Immediate surgery is not supported by current evidence. 5