General principals for taking NSAIDs.In general, it is best to take in the middle of a meal. Caution needs to be used in anyone with a history of sensitivity to aspirin. Sometimes individuals with asthma may have an exacerbation of their asthma with nonsteroidals. Caution certainly needs to be used in patients with a history of gastrointestinal bleeding and prior ulceration, in which case the selective COX-2 inhibitor Celebrex may be preferable. Caution is important in those patients with underlying kidney problems as all the nonsteroidals may worsen kidney function. Patients with any underlying liver function abnormalities need to be monitored closely. In patients who are taking Coumadin as an anticoagulant, only the NSAIDs that are the least irritating to the gastrointestinal tract should be utilized. COX-2 selective inhibitors are preferable, but it is still important to monitor the prothrombin times to make sure that these are not adversely affected. Also, the patient needs to be monitored to make sure that there is no gastrointestinal bleeding while on these medications in combination with an anticoagulant. This can be done by checking a blood count to make sure there is no anemia as well as checking stool samples for blood. Most of the standard nonsteroidal anti-inflammatory drugs interfere with platelet function and therefore promote easy bruising or bleeding. The exceptions to this are the non-acetylated aspirins, Relafen (nabumetone), and selective COX-2 inhibitors. The acetyl side group on aspirin is responsible for its effect on platelets and when this is not present, the potential for easy bruising is decreased. Celebrex, a selective COX-2 inhibitor, does not interfere with platelet function as there is no COX-2 enzyme in platelets.
|
Generic Name |
Brand Name |
Dosage |
Side-effects |
Comments |
|
diclofenac potassium |
Cataflam |
50 mg tid or qid |
GI irritation including
ulcers are a potential possibility, interference with renal function |
Useful as an alternative
to Voltaren in patients where additional sodium intake is a risk such
as a patient with congestive heart failure |
|
diclofenac sodium |
Voltaren, Voltaren XR |
50 mg bid or tid, or 75
mg bid. Voltaren XR is taken
100 mg once daily with food |
GI side-effects, interference
with renal function, possible change in liver function tests |
|
|
diclofenac sodium combined
with misoprostol |
Arthrotec (Voltaren plus
Cytotec) |
50 mg bid or tid |
In spite of the fact that
Cytotec is combined in this tablet to decrease GI irritation and the
risk of ulcer, there still may be GI side-effects. Cytotec itself may
cause abdominal discomfort, gas, bloating, diarrhea. Voltaren in the tablet may cause some GI irritation. There still may be liver function abnormalities
and changes in kidney function. |
A combination of Cytotec
with Voltaren is designed to increase compliance by being made together
in one tablet. A percentage
of patients will have trouble tolerating Cytotec due to its own set
of GI side-effects, even though it has been proven to be protective
as far as prevention of ulcers in the stomach |
|
diflunisal |
Dolobid |
500 mg bid or tid with
meals |
GI side-effects, kidney
function changes |
|
|
etodolac |
Lodine Lodine XL |
Usually 1200 mg per day
in divided dosages with food. Lodine
XL is a 400 mg tab often given as two with breakfast and one with supper |
GI side-effects, interference
with renal function. Low incidence
of any liver function abnormalities |
|
|
fenoprofen calcium |
Nalfon |
Usually 600 mg qid with
food |
Caution needs to be used
particularly regarding renal function, also GI irritation |
There have been infrequent
cases of interstitial nephritis with this drug, so careful monitoring
of renal function is in order |
|
flurbiprofen |
Ansaid |
100 mg bid or tid with
meals |
GI side-effects, renal
problems |
|
|
ibuprofen |
Motrin (OTC forms are Nuprin, Medipren, Advil or Motrin IB) |
2400 to 3200 mg per day
in divided dosages with food |
GI side-effects, kidney
function changes |
The minimum anti-inflammatory
dose of ibuprofen is 1600 mg per day, but 2400 to 3200 mg per day is
a better anti-inflammatory dose |
|
indomethacin |
Indocin Indocin SR |
50 mg bid or tid with meals.
Indocin SR is 75 mg bid with meals |
GI side-effects, renal
dysfunction |
Indocin is one of the more
potent anti-inflammatory medications.
It is particularly useful in treating crystal-induced arthritis
such as gout or pseudogout. It
is also effective in the group of arthritides called seronegative spondyloarthropathy
which includes ankylosing spondylitis, psoriatic arthritis and Reiter's
syndrome. Although it is a highly
effective anti-inflammatory medication, it does have a fair amount of
GI irritation associated with it. Some
patients, especially those over age 65, have had difficulty tolerating
Indocin because of its central nervous system side-effects which include
headache and confusion |
|
ketoprofen |
Orudis, Oruvail (OTC it comes as Orudis KT) |
50 mg tid with meals, or
Oruvail 200 mg once daily with food |
GI side-effects, kidney
function changes |
The once a day Oruvail
dosage does help with compliance as it is always easy to remember to
take an arthritis pill once daily |
|
meclofenamate sodium |
Meclomen |
100 mg bid or tid with
meals |
GI side-effects including
diarrhea, also kidney function changes |
|
|
mefenamic acid |
Ponstel |
250 mg caps, two caps initially
and then 250 mg q6h with food |
GI symptoms, hemolytic
anemia has been reported with prolonged usage of this drug. Central nervous system side effects may
occur with headache, dizziness, drowsiness, also kidney dysfunction
particularly a risk in elderly patients |
This is a nonsteroidal
that is used mainly as an analgesic (for pain relief) and sometimes
has been used for painful menses (short-term use).
It is not used on a long-term basis to treat arthritis. |
| meloxicam | Mobic |
7.5 mg tablets, 1 or 2 daily with food
15 mg tablets, 1 daily with food |
GI side effects may include abdominal pain, diarrhea, heartburn, nausea, and gas. Patients may develop gastro-inestinal ulcers with or without bleeding. Patients may develop swelling in the ankles (edema), itching of the skin (pruritus) or rash, dizziness or headaches. Patients may be found to have elevated liver functions in up to 15% of cases. In patients with marginal renal function, worsening of their kidney function may be noted after taking Mobic. | This medication is mid-way between the selective COX-2 inhibitors (such as Celebrex and Vioxx) and the traditional NSAIDs as far as GI safety. |
|
nabumetone |
Relafen |
500 mg one or two bid with
meals or 750 mg bid with meals |
GI irritation, kidney dysfunction |
|
|
naproxen |
Naprosyn Naprelan and Enteric
Coated Naprosyn |
500 mg bid or tid with
meals, Naprelan is 500 mg two or three tabs in a single dose with food,
Enteric Coated Naprosyn is similar to regular Naprosyn with 500 mg bid
or tid with meals |
GI side-effects, kidney
dysfunction |
|
|
naproxen sodium |
Anaprox, Anaprox DS (OTC
form is Aleve) |
Dosage of Anaprox is 275
mg one or two bid or tid with meals, Anaprox DS is 550 mg taken bid
or tid with meals, Aleve is 220 mg of naproxen.
If taken under a physicians supervision, Aleve may be taken as
up to two tabs bid or tid with meals |
GI side-effects, kidney
dysfunction |
There is a danger in taking
Aleve in significant dosages without being monitored by a physician.
Even though this is an OTC medication, patients need to have
assessments regarding their blood count, kidney function and liver tests.
Also it is extremely important that patients who are already
on another NSAID, do not add Aleve or ibuprofen as an OTC medication
to this. This only increases the likelihood of toxic
side-effects particularly regarding the stomach with risk of ulceration. |
|
oxaprozin |
Daypro |
600 mg usually three tabs
per day given as 600 mg bid with meals or two of the 600 mg tabs with
breakfast and one 600 mg tab with supper |
GI side-effects, kidney
test changes |
|
|
piroxicam |
Feldene |
20 mg once daily with breakfast
(or 10 mg bid with meals in patients who fail once a day dosing) |
GI side-effects, kidney
function abnormalities |
Feldene was one of the
first once a day NSAIDs. There
has been some controversy about whether it has an increased incidence
of GI bleeding compared to some of the other nonsteroidals. One of the arguments against this has been
the fact that patients have a high degree of compliance with Feldene
since it is mostly taken on a once a day basis versus other nonsteroidals
that have to be taken three or four times per day where patients may
skip or miss dosages. This,
it is argued, may account for some of the differences in the incidence
of GI bleeding. On the other hand since patients tend to
take their Feldene once a day on a regular basis, they do get the full
anti-inflammatory benefits of the medication. |
|
sulindac |
Clinoril |
200 mg bid with meals or
150 mg bid with meals |
GI side-effects, liver
function abnormalities with a small incidence of cholestatic hepatitis,
also changes in kidney function may occur |
Liver tests have to be
monitored closely with Clinoril. The
occurrence of hepatitis secondary to this medication usually will occur
in the first couple of months of its usage.
In patients with underlying renal disease, a case has been made
for Clinoril having fewer kidney problems than some of the other NSAIDs. |
|
tolmetin sodium |
Tolectin Tolectin DS |
400 mg qid with food or 600 mg tid with food Tolectin DS is 400 mg tid with meals |
GI side-effects, kidney
dysfunction |
|
|
Generic Name |
Brand Name |
Dosage |
Side-effects |
Comments |
|
aspirin |
Ascriptin Ecotrin Bayer
aspirin Bufferin Excedrin Anacin |
325 mg is regular strength,
500 mg is extra strength or arthritis strength. The usual dosage is 2,600 to 4,000 mg per
day in divided dosages with food |
GI irritation, hypersensitivity
reactions to aspirin with possible exacerbation of asthma (especially
in those individuals with polyps in their nose along with their asthma),
ringing in the ears with possible loss of hearing which may be dose
related |
Aspirin was the original
standard against which all of the NSAIDs were compared. In those patients who do not have any GI
problems, it is certainly the least expensive way to treat arthritis. The problem is mainly with GI intolerance
of this medicine in higher dosages. |
|
choline magnesium trisalicylate |
Trilisate Tricosal |
500 mg two bid or tid with
meals or 750 mg tid or qid with meals |
Ringing in the ears with
possible temporary loss of hearing, GI upset |
Prior to selective COX-2
inhibitors, this was one of the less irritating forms of anti-inflammatory
medications. It does not have
antiplatelet effects and therefore would not be a preventative as far
as stroke or heart attack. Also,
although it is less irritating on the GI tract, its efficacy is not
as high as some of the other nonsteroidals and therefore this becomes
a trade-off between efficacy and side-effects. |
|
magnesium salicylate |
Magan Mobidin |
2,600 to 4,800 mg per day
in divided dosages |
GI side-effects are possible
even though this is designed to be less irritating to the stomach, ringing
in the ears |
|
|
salsalate |
Disalcid Salflex |
500 mg two tid with meals
or 750 mg tid with meals |
GI symptoms still possible
even though less irritating to the GI tract, ringing in the ears with
possible temporary loss of hearing |
Once again, if you need
the antiplatelet effect for stroke and heart attack prevention, then
you will need to take one baby aspirin up to a full aspirin daily to
get that benefit as the salsalate will not provide this |
NSAIDS - Selective COX-2 Inhibitor (COX-1 sparing)
|
Generic Name |
Brand Name |
Dosage |
Side-effects |
Comments |
|
celecoxib |
Celebrex |
100 mg bid with meals or
200 mg once daily in osteoarthritis on up to 200 mg bid with meals in
rheumatoid arthritis |
Decreased incidence of
stomach ulcers. Decreased incidence
of antiplatelet effects which leads to decreased bleeding tendency or
bruising. Still has the potential
for kidney dysfunction |
Need to monitor pro-times
and INR with patient on Coumadin, although overall safer than traditional
nonsteroidal anti-inflammatory drugs for use with Coumadin. In patients where aspirin is needed to prevent
a future stroke or myocardial infarction (heart attack), then one coated
aspirin per day may be used safely with Celebrex.
Patients who have a true allergy to sulfonamide antibiotics such
as Bactrim or Septra DS should avoid Celebrex as it does have a sulfonamide
side chain and this may lead to the formation of a rash and other allergic
symptoms |
Return to Medications Home Page
Return to ArthritisCentral.com Home Page