What is the first‑line NSAID for a typical adult with pre‑patellar (house‑maid’s) bursitis who has no gastrointestinal ulcer disease, chronic kidney disease, uncontrolled hypertension, or cardiovascular risk?

Best NSAID for Pre-Patellar Bursitis

For a typical adult with non-septic pre-patellar bursitis and no contraindications, ibuprofen at the lowest effective dose (400–800 mg three times daily) is the preferred first-line NSAID, combined with ice, rest, elevation, and activity modification. 1, 2, 3

Initial Assessment and Differentiation

Before selecting any NSAID, you must first distinguish septic from non-septic bursitis, as this fundamentally changes management:

• Septic bursitis is suggested by fever >37.8°C, prebursal temperature difference >2.2°C, skin lesions overlying the bursa, or systemic signs of infection 1
• Bursal aspiration should be performed if infection is suspected, with fluid analyzed for white cell count (>3,000 cells/μL suggests septic), polymorphonuclear cells (>50% suggests septic), glucose ratio (fluid-to-serum <50% suggests septic), Gram stain, and culture 1
• If septic bursitis is confirmed, NSAIDs are adjunctive only—antibiotics targeting Staphylococcus aureus become the primary treatment 3, 4

NSAID Selection for Non-Septic Bursitis

First-Line: Ibuprofen

• Ibuprofen is the preferred NSAID because it achieves adequate analgesic effect at doses with relatively low anti-inflammatory activity, making it less ulcerogenic than NSAIDs requiring high anti-inflammatory doses (e.g., piroxicam) 5
• Prescribe 400–800 mg three times daily (total 1,200–2,400 mg/day) for the shortest duration necessary 5
• At full anti-inflammatory doses (≥2,400 mg/day), ibuprofen's GI bleeding risk becomes comparable to other NSAIDs, so use the lowest effective dose 5

Alternative: Naproxen

• Naproxen is an acceptable alternative, particularly if twice-daily dosing improves adherence, and may be preferred in patients with moderate cardiovascular risk who cannot avoid NSAIDs 6
• Dose: 250–500 mg twice daily 6

COX-2 Selective Inhibitors (Celecoxib)

• Celecoxib 200 mg once or twice daily may be considered if the patient has moderate GI risk (one to two risk factors such as age >60, prior uncomplicated ulcer, or concurrent low-dose aspirin) 5
• Celecoxib reduces symptomatic ulcers by 50–90% compared to non-selective NSAIDs but is contraindicated in patients with uncontrolled hypertension or established cardiovascular disease 5, 6

Mandatory Co-Therapy and Monitoring

Gastroprotection

• All patients with increased GI risk (age >65, history of peptic ulcer, concurrent corticosteroids, anticoagulants, or aspirin) require either:
  • Non-selective NSAID plus a proton pump inhibitor (PPI), or
  • A selective COX-2 inhibitor alone (moderate risk), or
  • A selective COX-2 inhibitor plus PPI (high risk) 5

Blood Pressure and Renal Monitoring

• Measure blood pressure before initiating NSAID therapy and monitor during treatment, as NSAIDs can elevate blood pressure and exacerbate hypertension 6
• Screen for chronic kidney disease in high-risk patients (elderly, diabetic, hypertensive) before starting NSAIDs, and avoid NSAIDs entirely in severe CKD 6
• NSAIDs are contraindicated in patients with treatment-resistant hypertension, high cardiovascular risk, or severe renal impairment 6

Core Conservative Measures (Always Combined with NSAIDs)

• Bursal aspiration may shorten symptom duration in acute traumatic/hemorrhagic bursitis but is generally not recommended for chronic microtraumatic bursitis due to the risk of introducing infection 3
• Ice, rest, elevation, and activity modification (avoiding kneeling or direct pressure on the prepatellar bursa) are essential adjuncts to NSAID therapy 1, 2, 3
• Analgesics such as acetaminophen (up to 3,000–4,000 mg/day) can be added for additional pain control without increasing NSAID dose 7

Intrabursal Corticosteroid Injection

• Corticosteroid injection into the prepatellar bursa is sometimes used for chronic microtraumatic bursitis, but high-quality evidence demonstrating benefit is unavailable 3
• Injection may be considered in patients with high athletic or occupational demands who have failed conservative therapy, but it carries a risk of introducing infection if the bursa is not definitively non-septic 1, 3

When to Escalate or Refer

• Surgical bursectomy (endoscopic or open) is reserved for recalcitrant cases that fail 6–8 weeks of conservative management, recurrent bursitis, or septic bursitis unresponsive to antibiotics 1, 2, 4
• Endoscopic bursectomy is non-inferior to open bursectomy in recurrence rates and complications, with the advantage of shorter hospital stay and lower post-operative pain 4

Critical Safety Pitfalls

• Never prescribe NSAIDs without assessing cardiovascular, renal, and GI risk factors—age, hypertension, heart failure, CKD, prior ulcer, and concurrent anticoagulants or aspirin all increase adverse event risk 5, 6
• Never use NSAIDs in patients with uncontrolled hypertension (systolic ≥140 mm Hg or diastolic ≥90 mm Hg) until blood pressure is controlled 6
• Never prescribe oral NSAIDs to elderly patients (≥65 years) without gastroprotection (PPI co-prescription) 5
• Do not perform intrabursal corticosteroid injection if septic bursitis has not been definitively ruled out, as this can worsen infection 3
• Avoid routine bursal aspiration in chronic microtraumatic bursitis unless infection is suspected, as it introduces iatrogenic infection risk 3