NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)




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Aspirin | Acetylsalicylic acid | ASA

Dosage forms

  • Aspirin is available over-the-counter in many different brands (e.g. Bayer®, St. Joseph®, Bufferin®, etc.)
  • Aspirin comes in tablets, caplets, buffered forms, enteric-coated forms, and chewable pills
  • Most common dosage forms are 81, 325, and 500 mg

Dosing - Adults

Analgesic/antipyretic
  • 325 - 1000 mg every 6 hours as needed
  • Do not exceed 4000 mg/day
Acute heart attack
  • 162 - 325 mg of non-enteric coated aspirin, chewed or swallowed
  • AHA recommendation
Secondary prevention of coronary artery disease
Primary prevention of cardiovascular disease and colorectal cancer
  • 81 mg once daily
  • See aspirin for more
  • USPSTF recommendation
Dual antiplatelet therapy (with P2Y12 inhibitor)

Dosing - Children

  • With a few exceptions, aspirin is not recommended in children and teenagers because of the risk of Reye's syndrome

Other

  • See aspirin for a comprehensive review of aspirin including its use in cardiovascular disease and other disease prevention

Generic / Price

- YES/$

Diflunisal (Dolobid®)

Dosage forms

Tablet
  • 500 mg

Dosing

Mild to moderate pain
  • Initial dose of 1000 mg followed by 500 mg every 12 hours as needed
  • Some patients may require 500 mg every 8 hours
  • Do not exceed 1500 mg/day
Osteoarthritis
  • 500 -1000 mg/day given in two divided doses
  • Do not exceed 1500 mg/day
Rheumatoid arthritis
  • 500 -1000 mg/day given in two divided doses
  • Do not exceed 1500 mg/day

Other

  • Half-life: 8 - 12 hours

Generic / Price

- YES/$

Fenoprofen (Nalfon®)

Dosage forms

Tablet
  • 600 mg

Dosing

Mild to moderate pain
  • 200 mg every 4 - 6 hours as needed
Osteoarthritis
  • 400 - 600 mg three to four times a day as needed
  • Do not exceed 3200 mg/day
Rheumatoid arthritis
  • 400 - 600 mg three to four times a day as needed
  • Do not exceed 3200 mg/day

Other

  • Half-life: 3 hours
  • Taking with food may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.

Generic / Price

- YES/$$

Flurbiprofen (Ansaid®)

Dosage forms

Tablet
  • 50 mg
  • 100 mg

Dosing

Osteoarthritis
  • 50 - 100 mg two to four times a day as needed
  • Recommended starting dose is 200 - 300 mg/day
Rheumatoid arthritis
  • 50 - 100 mg two to four times a day as needed
  • Recommended starting dose is 200 - 300 mg/day

Other

  • Half-life: 5.7 hours
  • Taking with food may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.

Generic / Price

- YES/$

Ibuprofen | Advil® | Motrin®

Dosage forms

Tablet
  • 200 mg (OTC)
  • 400 mg
  • 600 mg
  • 800 mg
Suspension (Children's Motrin®)
  • 100 mg/5 ml (OTC)
Drops (Infants' Motrin®)
  • 50 mg/1.25ml (OTC)

Dosing (6 months - 2 years)

Pain/fever
  • Dosing based on infant drops (50 mg/1.25ml)
  • May repeat dose every 6 - 8 hours
  • Do not give more than 4 doses a day

Weight (lbs) Weight (kg) Age (months) Dose
Under 6 months Not well studied
12 - 17 5.4 - 8.1 6 - 11 1.25 ml (50 mg)
18 - 23 8.2 - 10.8 12 - 23 1.875 ml (75 mg)
Alternative: 5 - 10 mg/kg/dose


Dosing (2 - 11 years)

Pain/fever
  • May repeat dose every 6 - 8 hours
  • Do not give more than 4 doses a day

Weight (lbs) Weight (kg) Age (years) Dose (mg)
24 - 35 10.9 - 16.3 2 - 3 100
36 - 47 16.4 - 21.7 4 - 5 150
48 - 59 21.8 - 27.2 6 - 8 200
60 - 71 27.3 - 32.6 9 - 10 250
72 - 95 32.7 - 43.2 11 300
Alternative: 5 - 10 mg/kg/dose (max 400 mg)


Dosing (Adults)

Mild to moderate pain
  • 400 mg every 4 - 6 hours as needed
  • In trials, doses above 400 mg were not more effective than 400 mg
Dysmenorrhea
  • 400 mg every 4 hours as needed
Osteoarthritis
  • 400 - 800 mg three to four times a day
  • In trials, daily doses above 2400 mg were not more effective than 2400 mg/day
Rheumatoid arthritis
  • 400 - 800 mg three to four times a day
  • In trials, daily doses above 2400 mg were not more effective than 2400 mg/day

Efficacy


Other

  • Half-life: 2.2 hours
  • Taking after a meal may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.

Generic / Price

- YES/$ (all forms)

Ibuprofen + Famotidine (Duexis®)

Dosage forms

Tablet
  • Famotidine : Ibuprofen
    • 26.6 mg : 800 mg

Dosing

Osteoarthritis
  • 1 tablet three times a day as needed
Rheumatoid arthritis
  • 1 tablet three times a day as needed

Other

  • Ibuprofen half-life: 2.2 hours
  • Food may delay absorption
  • Famotidine (Pepcid) is a H2 blocker that may help prevent NSAID-induced peptic ulcers
  • Do not cut or crush tablets

Generic / Price

- NO/$$$$

Indomethacin IR (Indocin®)

Dosage forms

Capsule
  • 25 mg
  • 50 mg
Suspension
  • 25 mg/5 ml
  • Comes in bottles of 237 ml
Suppository
  • 50 mg
  • Comes in box of 30

Dosing

Acute gout
  • 50 mg three times a day until pain is tolerable then taper
Osteoarthritis
  • Starting: 25 mg two to three times a day
  • Increase daily dose by 25 - 50 mg at weekly intervals to a maximum of 200 mg/day
Rheumatoid arthritis
  • Starting: 25 mg two to three times a day
  • Increase daily dose by 25 - 50 mg at weekly intervals to a maximum of 200 mg/day
Ankylosing spondylitis
  • Starting: 25 mg two to three times a day
  • Increase daily dose by 25 - 50 mg at weekly intervals to a maximum of 200 mg/day
Painful shoulder
  • 75 - 150 mg/day given in 3 - 4 divided doses

Other

  • Half-life: 4.5 hours
  • Suppositories should be refrigerated

Generic / Price

  • Capsule (#30) - YES/$
  • Suspension (#30) - NO/$$$$
  • Suppository (#30) - NO/$$$$

Indomethacin ER (Indocin SR®)

Dosage forms

Capsule, extended-release
  • 75 mg

Dosing

Osteoarthritis
  • Starting: 75 mg once daily
  • May increase to 75 mg twice a day if necessary
Rheumatoid arthritis
  • Starting: 75 mg once daily
  • May increase to 75 mg twice a day if necessary
Ankylosing spondylitis
  • Starting: 75 mg once daily
  • May increase to 75 mg twice a day if necessary
Painful shoulder
  • 75 mg given once or twice a day as needed

Other

  • Give capsules with food to decrease gastric irritation
  • Extended-release capsules are not recommended for acute gout

Generic / Price

- YES/$

Ketoprofen (Orudis®)

Dosage forms

Capsule
  • 25 mg
  • 50 mg
  • 75 mg

Dosing

Mild to moderate pain
  • 25 - 50 mg every 6 - 8 hours as needed
  • Do not exceed 300 mg/day
Osteoarthritis
  • 75 mg three times a day as needed or 50 mg four times a day as needed
  • Do not exceed 300 mg/day
Rheumatoid arthritis
  • 75 mg three times a day as needed or 50 mg four times a day as needed
  • Do not exceed 300 mg/day
Dysmenorrhea
  • 25 - 50 mg every 6 - 8 hours as needed
  • Do not exceed 300 mg/day

Other

  • Half-life: 2 hours
  • Taking with food may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.
  • Doses above 200 mg/day have not been shown to increase effectiveness
  • Dose should be reduced in kidney and liver disease. See precautions below.
  • Use lower doses in patients ≥ 75 years
  • Use lower doses in smaller individuals

Generic / Price

- YES/$

Ketoprofen ER (Oruvail®)

Dosage forms

Capsule, extended-release
  • 100 mg
  • 150 mg
  • 200 mg

Dosing

Osteoarthritis
  • 200 mg once daily day as needed
  • Do not exceed 200 mg/day
Rheumatoid arthritis
  • 200 mg once daily day as needed
  • Do not exceed 200 mg/day

Other

  • Half-life: 5.4 hours
  • Taking with food may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.
  • Dose should be reduced in kidney and liver disease. See precautions below.
  • Use lower doses in patients ≥ 75 years
  • Use lower doses in smaller individuals

Generic / Price

- YES/$$$ (30 capsules)

Ketorolac tromethamine (Toradol®)

Dosage forms

Tablet
  • 10 mg

Dosing

Moderate to severe pain
  • Ketorolac tablets are only recommended as continuation therapy after ketorolac has been started by the IV or IM route
  • Total course of therapy (parenteral + oral) should not exceed 5 days
  • The total daily dose should not exceed 40 mg in any patient

Patients Recommended dose
Age 17 - 64 years
  • 20 mg once, then 10 mg every 4 - 6 hours as needed
Any of the following:
  • Age ≥ 65 years
  • Renal impairment
  • Weight < 50 kg (110 lbs)
  • 10 mg once, then 10 mg every 4 - 6 hours as needed


Other

  • Half-life: 5 - 6 hours

Generic / Price

- YES/$

Ketorolac (Sprix®)

Dosage forms

Nasal spray
  • Comes in single-day sprayer that delivers 8 sprays
  • Each spray delivers 15.75 mg of ketorolac
  • Comes in box of 5 sprayers

Dosing

Moderate to severe pain
  • Sprix may be initiated without prior parenteral ketorolac therapy
  • Total course of therapy (parenteral + oral + spray) should not exceed 5 days

Patients Recommended dose
Age 18 - 64 years
  • One spray in each nostril (31.5 mg total) every 6 - 8 hours as needed
  • Do not exceed 4 doses/day (126 mg)
Any of the following:
  • Age ≥ 65 years
  • Renal impairment
  • Weight < 50 kg (110 lbs)
  • One spray in one nostril (15.75 mg) every 6 - 8 hours as needed
  • Do not exceed 4 doses/day (63 mg)


Other

  • Half-life: 5 - 6 hours
  • Do not use one spray bottle for more than 24 hours. After 24 hours, it will not deliver intended dose.
  • Keep unopened sprayers refrigerated
  • Open sprayers may be kept at room temperature. Protect from sunlight.

Generic / Price

- NO/$$$$ (5 bottles)

Meclofenamate

Dosage forms

Capsule (Meclodium®)
  • 50 mg
  • 100 mg

Dosing

Mild to moderate pain
  • 50 - 100 mg every 4 - 6 hours as needed
  • Do not exceed 400 mg/day
Osteoarthritis
  • 200 - 400 mg/day given in 3 -4 equal doses
  • Do not exceed 400 mg/day
Rheumatoid arthritis
  • 200 - 400 mg/day given in 3 -4 equal doses
  • Do not exceed 400 mg/day
Dysmenorrhea and excessive menstrual blood loss
  • 100 mg three times a day for up to 6 days
  • Should be given at start of menstrual flow

Other

  • Half-life: Parent compound - 1.3 hours | Active metabolite - 15 hours
  • Food decreases the rate and extent of absorption

Generic / Price

- YES/$$-$$$$ (30 capsules)

Mefenamic acid (Ponstel®)

Dosage forms

Capsule
  • 250 mg

Dosing (≥ 14 years old)

Acute pain
  • Give 500 mg initially followed by 250 mg every 6 hours as needed
  • Therapy should not typically exceed a week
Dysmenorrhea
  • Give 500 mg initially followed by 250 mg every 6 hours as needed
  • Begin treatment with start of menses and take for 2 - 3 days

Other

  • Half-life: 2 hours

Generic / Price

- YES/$$$ (30 capsules)

Nabumetone (Relafen®)

Dosage forms

Tablet
  • 500 mg
  • 750 mg

Dosing

Osteoarthritis
  • 1000 mg once daily as needed
  • May increase dose up to 2000 mg/day if necessary
  • Daily dose may be given in one or two divided doses
  • Do not exceed 2000 mg/day
Rheumatoid arthritis
  • 1000 mg once daily as needed
  • May increase dose up to 2000 mg/day if necessary
  • Daily dose may be given in one or two divided doses
  • Do not exceed 2000 mg/day

Other

  • Half-life: 24 hours
  • The manufacturer states that in trials, nabumetone had little effect on collagen-induced platelet aggregation and no effect on bleeding time
  • May take with or without food
  • Patients who weigh < 50 kg (110 lbs) may respond to lower doses

Generic / Price

- YES/$

Naproxen IR | Naprosyn® | Aleve® | Anaprox®

Dosage forms

Tablets, gelcaps, caplets (Aleve®, Anaprox®)
  • Naproxen : Sodium
    • 200 mg : 20 mg (OTC)
    • 250 mg : 25 mg
    • 500 mg : 50 mg
Tablet (Naprosyn®)
  • 250 mg
  • 375 mg
  • 500 mg
Tablet, enteric-coated(EC-Naprosyn®)
  • 375 mg
  • 500 mg
Suspension (Naprosyn®)
  • 25 mg/ml

Dosing (Children ≥ 2 years)

NOTE: Dosing based on naproxen component
Juvenile arthritis
  • 5 mg/kg/dose twice a day as needed
Other (pain, fever, etc.)
  • 2.5 - 5 mg/kg/dose two to three times a day as needed
  • Do not exceed 15 mg/kg/day

Dosing (Adults)

Osteoarthritis, Rheumatoid arthritis, Ankylosing spondylitis
  • 250 - 500 mg twice daily as needed
Pain, Dysmenorrhea, Tendonitis, Bursitis
  • 500 mg initially followed by 500 mg every 12 hours as needed or 250 mg every 6 - 8 hours as needed
Acute gout
  • 750 mg initially followed by 250 mg every 8 hours until pain subsides

Efficacy


Other

  • Half-life: 12 - 17 hours
  • May take with or without food
  • Naproxen sodium has a quicker onset of action (30 minutes) than naproxen (1 hour)
  • Enteric-coated naprosyn is not recommended in gout or acute pain because of delayed absorption

Generic / Price

- YES/$ (all forms)

Naproxen ER (Naprelan®)

Dosage forms

Tablets, extended-release
  • 375 mg
  • 500 mg
  • 750 mg
  • Strength based on naproxen component
  • Contains naproxen sodium

Dosing

Osteoarthritis, Rheumatoid arthritis, Ankylosing spondylitis
  • 750 - 1000 mg once daily as needed
  • Maximum dose is 1500 once daily
Pain, Dysmenorrhea, Tendonitis, Bursitis
  • 1000 mg once daily as needed
  • May increase to 1500 mg once daily for short period if necessary
Acute gout
  • 1000 - 1500 mg once daily on Day 1, then 1000 mg once daily until attack resolves

Other

  • Half-life: 15 hours
  • May take with or without food
  • For patients taking standard-release naproxen, the total daily dose of standard-release naproxen may be given as a once daily dose of extended-release naproxen

Generic / Price

- YES/$$$$ (60 tablets)

Naproxen + Esomeprazole (Vimovo®)

Dosage forms

Tablets, enteric-coated
  • Naproxen : Esomeprazole
    • 375 mg : 20 mg
    • 500 mg : 20 mg

Dosing

Osteoarthritis, Rheumatoid arthritis, Ankylosing spondylitis
  • 375 - 500 mg twice a day as needed

Other

  • Half-life (naproxen): 15 hours
  • Take at least 30 minutes before meals
  • Do not crush, cut, or chew tablets
  • Vimovo is not recommended for acute pain because absorption is delayed
  • Esomeprazole is a proton pump inhibitor (Nexium) that protects against gastrointestinal irritation
  • See the Nexium PI for precautions, warnings, and drug interactions regarding esomeprazole

Generic / Price

- NO/$$$$

Oxaprozin (Daypro®)

Dosage forms

Tablet
  • 600 mg

Dosing (6 - 16 years)

Juvenile rheumatoid arthritis
  • Give as once daily dose

Body weight (kg) Body weight (lbs) Daily dose
22 - 31 48 - 68 600 mg
32 - 54 69 - 119 900 mg
≥ 55 ≥ 120 1200 mg


Dosing (Adults)

Osteoarthritis
  • 1200 mg once daily as needed
  • Maximum dose is 1800 mg/day or 26 mg/kg/day, whichever is lower. Give in divided doses.
  • Patients with lower body weight should start with 600 mg once daily
  • A one-time loading dose of 1200 - 1800 mg (not to exceed 26 mg/kg) may be given when a quicker onset of action is desired
Rheumatoid arthritis
  • 1200 mg once daily as needed
  • Maximum dose is 1800 mg/day or 26 mg/kg/day, whichever is lower. Give in divided doses.
  • Patients with lower body weight should start with 600 mg once daily
  • A one-time loading dose of 1200 - 1800 mg (not to exceed 26 mg/kg) may be given when a quicker onset of action is desired

Other

  • Half-life: 55 hours (single dose) | 41 hours (multiple doses)
  • Food may decrease the rate of absorption. Extent of absorption is not affected.

Generic / Price

- YES/$$ (60 tablets)

Sulindac (Clinoril®)

Dosage forms

Tablet
  • 150 mg
  • 200 mg

Dosing

Osteoarthritis, Rheumatoid arthritis, Ankylosing spondylitis
  • 150 - 200 mg twice a day as needed
  • Do not exceed 400 mg/day
Painful shoulder, Tendonitis, Bursitis
  • 200 mg twice a day as needed
  • Do not exceed 400 mg/day
Acute gout
  • 200 mg twice a day until satisfactory response, then taper
  • Do not exceed 400 mg/day

Other

  • Half-life: 16.4 hours
  • Take with food

Generic / Price

- YES/$

Tolmetin (Tolectin®)

Dosage forms

Tablet
  • 200 mg
  • 600 mg
Capsule
  • 400 mg

Dosing (Children ≥ 2 years old)

Juvenile rheumatoid arthritis
  • 20 mg/kg/day given in three or four divided doses
  • Usual dosage range is 15 - 30 mg/kg/day
  • Do not exceed 30 mg/kg/day

Dosing (Adults)

Osteoarthritis
  • 400 mg three times a day as needed
  • May increase to 600 mg three times a day
  • Do not exceed 1800 mg/day
Rheumatoid arthritis
  • 400 mg three times a day as needed
  • May increase to 600 mg three times a day
  • Do not exceed 1800 mg/day

Other

  • Half-life: 5 hours
  • Food decreases bioavailability
  • Do not give with sodium bicarbonate antacids

Generic / Price

  • Generic (60 tablets) - $$$$
  • Generic (60 capsules) - $$-$$$


Diclofenac potassium IR (Cataflam®)

Dosage forms

Tablet
  • 50 mg

Dosing

Pain or primary dysmenorrhea
  • 50 mg three times a day as needed
  • Initial dose of 100 mg may be given
Osteoarthritis
  • 50 mg two to three times a day as needed
Rheumatoid arthritis
  • 50 mg three to four times a day as needed

Other

  • Half-life: 1.9 hours
  • Taking with food may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.
  • Cataflam is diclofenac potassium. Cataflam is not bioequivalent with diclofenac sodium on a mg-to-mg basis

Generic / Price

- YES/$

Diclofenac sodium EC (Voltaren®)

Dosage forms

Tablet, delayed-release
  • 25 mg
  • 50 mg
  • 75 mg
  • Tablets are enteric-coated

Dosing

Osteoarthritis
  • 50 mg two to three times a day as needed or 75 mg two times a day as needed
Rheumatoid arthritis
  • 50 mg three to four times a day as needed or 75 mg two times a day as needed
  • Do not exceed 225 mg/day
Ankylosing spondylitis
  • 25 mg four times a day with an extra 25 mg at bedtime if necessary

Other

  • Half-life: 2 hours
  • Taking with food may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.
  • Voltaren is diclofenac sodium. Voltaren is not bioequivalent with diclofenac potassium on a mg-to-mg basis
  • Tablets are enteric-coated
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- YES/$

Diclofenac sodium ER (Voltaren XR®)

Dosage forms

Tablet, extended-release
  • 100 mg

Dosing

Osteoarthritis
  • 100 mg once daily as needed
Rheumatoid arthritis
  • 100 mg once daily as needed
  • In rare cases, 100 mg twice a day may be used

Other

  • Taking with food may delay absorption and increase peak plasma levels. Extent of absorption is not affected.
  • Voltaren is not bioequivalent with diclofenac potassium on a mg-to-mg basis
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- YES/$

Diclofenac sodium (Voltaren® Gel)

Dosage forms

Gel
  • 1%
  • Comes in 100 gram tube
  • Available OTC

Dosing

Osteoarthritis of knees, ankles, and feet
  • Apply 4 grams to affected joint 4 times a day as needed
Osteoarthritis of elbows, wrists, and hands
  • Apply 2 grams to affected joint 4 times a day as needed

Other

  • Comes with dosing card for measuring and application
  • Total dose should not exceed 32 g per day, over all affected joints
  • Avoid bathing for at least 1 hour after application
  • Avoid sunlight/heat exposure to treated joints
  • Avoid clothing over treated joints for 10 minutes after applying
  • Systemic exposure from gel is ∼ 6% of that seen with the oral form of diclofenac
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- YES/$ (100g tube)

Diclofenac potassium (Zipsor®)

Dosage forms

Capsule, liquid filled
  • 25 mg
  • Diclofenac potassium

Dosing

Mild to moderate acute pain
  • 25 mg four times a day as needed

Other

  • Half-life: 1 hour
  • Taking with food may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.
  • Zipsor is diclofenac potassium. Zipsor is not bioequivalent with other diclofenac preparations on a mg-to-mg basis
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- NO/$$$$

Diclofenac (Zorvolex®)

Dosage forms

Capsule
  • 18 mg
  • 35 mg

Dosing

Acute pain
  • 18 - 35 mg three times a day as needed
Osteoarthritis
  • 35 mg three times a day as needed

Other

  • Half-life: 2 hours
  • Taking with food may decrease absorption and lower effectiveness
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- NO/$$$$

Diclofenac potassium (Cambia®)

Dosage forms

Powder for solution
  • 50 mg packet of powder
  • Comes in box of 9 packets

Dosing

Acute migraine with or without aura
  • 50 mg (one packet) with start of acute migraine
  • Safety and effectiveness of second dose has not been established

Other

  • Half-life: 2 hours
  • Mix contents of packet with 30 - 60 mls of water
  • Only mix with water. Drink immediately.
  • Taking with food may decrease absorption and lower effectiveness
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- NO/$$$$ (9 packets)

Diclofenac + Misoprostol (Arthrotec®)

Dosage forms

Tablet
  • Diclofenac : Misoprostol
    • 50 mg : 200 mcg
    • 75 mg : 200 mcg
    • Contains diclofenac sodium

Dosing

Osteoarthritis
  • 50 mg two to three times a day as needed or 75 mg twice a day as needed
Rheumatoid arthritis
  • 50 mg two to four times a day as needed or 75 mg twice a day as needed

Other

  • Half-life: 2 hours
  • DO NOT GIVE to pregnant women
  • Misoprostol is a synthetic prostaglandin E1 analog with gastric antisecretory and mucosal protective properties
  • Misoprostol may cause diarrhea, abdominal pain, nausea, and flatulence
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- YES/$-$$ (30 tablets)

Diclofenac (Flector®)

Dosage forms

Patch
  • 1.3% patch
  • Patch is 10 X 14 cm (3.9" X 5.5")
  • Each patch contains 180 mg of diclofenac
  • Comes in box of 30 patches

Dosing

Local acute pain due to strains, sprains, and contusions
  • 1 patch to most painful area twice a day

Other

  • Do not wear when bathing or showering. Do not place on non-intact or damaged skin.
  • May wear mesh sleeve over patch to hold in place
  • Systemic exposure to diclofenac after repeated patch use for four days was lower (< 1%) than that of a single oral 50 mg diclofenac sodium tablet
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- NO/$$$$ (30 patches)

Diclofenac (Pennsaid®)

Dosage forms

Solution
  • 16.05 mg/ml (1.5%)
  • Comes in 150 ml bottle

Dosing

Osteoarthritis of the knee
  • Apply 40 drops to affected knee 4 times a day as needed

Other

  • Avoid bathing for at least 30 minutes after application
  • Avoid sunlight/heat exposure to treated joints
  • Avoid clothing over treated joint until it is dry
  • Systemic exposure does occur, but is much less than with oral forms
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- YES/$ (150 ml)

Etodolac IR (Lodine®)

Dosage forms

Capsule
  • 200 mg
  • 300 mg
Tablet
  • 400 mg
  • 500 mg

Dosing

Acute pain
  • 200 - 400 mg every 6 - 8 hours as needed
  • Doses above 1000 mg/day have not been studied
Osteoarthritis
  • 300 - 500 mg twice a day as needed or 300 mg three times a day as needed
  • Doses above 1000 mg/day have not been studied
Rheumatoid arthritis
  • 300 - 500 mg twice a day as needed or 300 mg three times a day as needed
  • Doses above 1000 mg/day have not been studied

Other

  • Half-life 6.4 hours
  • Taking with food may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.
  • Etodolac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- YES/$

Etodolac ER (Lodine XL®)

Dosage forms

Tablet, extended-release
  • 400 mg
  • 500 mg
  • 600 mg

Dosing (6 - 16 years)

Juvenile rheumatoid arthritis
  • 20 - 30 kg: 400 mg once daily
  • 31 - 45 kg: 600 mg once daily
  • 46 - 60 kg: 800 mg once daily
  • > 60 kg: 1000 mg once daily

Dosing (Adults)

Osteoarthritis
  • 400 - 1000 mg once daily as needed
Rheumatoid arthritis
  • 400 - 1000 mg once daily as needed

Other

  • Half-life: 8.4 hours
  • Food may increase the rate of absorption. Extent of absorption is not affected.
  • Etodolac is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- YES/$ (30 tablets)

Meloxicam (Mobic®)

Dosage forms

Tablet
  • 7.5 mg
  • 15 mg
Suspension
  • 7.5 mg/5 ml
  • Comes in 100 ml bottle

Dosing (Children ≥ 2 years old)

Juvenile rheumatoid arthritis
  • 0.125 mg/kg once daily
  • Do not exceed 7.5 mg/day

Dosing (Adults)

Osteoarthritis
  • 7.5 - 15 mg once daily
Rheumatoid arthritis
  • 7.5 - 15 mg once daily

Other

  • Half-life: 15 - 20 hours
  • May take with or without food
  • Meloxicam is partially COX-2 selective. See COX selectivity for more.

Generic / Price

  • 30 tablets - YES/$
  • Solution 100 ml - YES/$$

Meloxicam (Vivlodex®)

Dosage forms

Capsule
  • 5 mg
  • 10 mg

Dosing

Osteoarthritis
  • 5 - 10 mg once daily
  • Do not exceed 10 mg/day

Other

  • Half-life: 22 hours
  • Food may decrease rate of absorption, but extent of absorption is not affected. May take without regard to meals.

Generic / Price

- NO/$$$$

Piroxicam (Feldene®)

Dosage forms

Capsule
  • 10 mg
  • 20 mg

Dosing

Osteoarthritis
  • 20 mg once daily as needed
  • Dose may be divided if desired
Rheumatoid arthritis
  • 20 mg once daily as needed
  • Dose may be divided if desired

Other

  • Half-life: 50 hours
  • Food may decrease the rate of absorption. Extent of absorption is not affected.
  • Piroxicam has a long half-life (50 hours), therefore, the full effect of the drug may not be seen for 7 - 12 days
  • Piroxicam is partially COX-2 selective. See COX selectivity for more.

Generic / Price

- YES/$



Celecoxib (Celebrex®)

Dosage forms

Capsule
  • 50 mg
  • 100 mg
  • 200 mg
  • 400 mg

Dosing (Children ≥ 2 years)

Juvenile rheumatoid arthritis
  • Weight ≥ 10 kg - ≤ 25 kg: 50 mg twice a day
  • Weight > 25 kg: 100 mg twice a day

Dosing (Adults)

Osteoarthritis
  • 200 mg once daily as needed or 100 mg twice a day as needed
Rheumatoid arthritis
  • 100 - 200 mg twice a day as needed
Acute pain and dysmenorrhea
  • 400 mg initially followed by an additional 200 mg on the first day if needed. On subsequent days, 200 mg twice a day as needed.
Ankylosing spondylitis
  • 200 mg once daily as needed or 100 mg twice a day as needed
  • If necessary, may increase to 400 mg/day after 6 weeks

Efficacy


Other

  • Half-life: 11 hours
  • The manufacturer states that in trials, celecoxib had no effect on reduction of platelet aggregation or increase in bleeding time
  • For doses up to 200 mg twice a day, celecoxib may be taken without regard to food. For doses ≥ 400 mg twice a day, celecoxib should be taken with food to improve absorption.
  • Capsules may be opened and sprinkled on applesauce
  • Celecoxib is a COX-2 selective NSAID

Generic / Price

- YES/$ (60 capsules)

Consensi® (amlodipine + celecoxib)

Dosage forms

Tablet
  • Amlodipine - Celecoxib
    • 2.5 mg - 200 mg
    • 5 mg - 200 mg
    • 10 mg - 200 mg

Dosing

Hypertension / Osteoarthritis
  • Starting: 2.5 - 5 mg/200 mg once daily
  • Maintenance: 2.5 - 10 mg/200 mg once daily
  • Max: 10 mg/200 mg once daily
  • Adjust dose every 7 - 14 days
  • May take without regard to food
  • Amlodipine is a calcium channel blocker

Generic / Price

- NO/$$$$












  • References [12,13]
Salicylates Propionic acids
  • Aspirin
  • Salsalate
  • Diflunisal
  • Ibuprofen (Motrin®, Advil®)
  • Naproxen (Naprosyn®, Aleve®)
  • Ketoprofen
  • Flurbiprofen (Ansaid®)
  • Fenoprofen (Nalfon®)
  • Oxaprozin (Daypro®)
Enolic acids Acetic acids
  • Meloxicam (Mobic®)
  • Piroxicam (Feldene®)
  • Diclofenac (Voltaren®)
  • Etodolac (Lodine®)
  • Indomethacin (Indocin®)
  • Ketorolac (Toradol®)
  • Sulindac (Clinoril®)
  • Tolmetin
Fenamic acids Nonacidic
  • Meclofenamate
  • Mefenamic acid (Ponstel®)
  • Nabumetone (Relafen®)





PRECISION study - Celecoxib vs Ibuprofen vs Naproxen for Cardiovascular Death, NEJM (2016) [PubMed abstract]
  • The PRECISION study enrolled 24,081 patients with established CVD or risk factors for CVD who required daily treatment with NSAIDs
Main inclusion criteria
  • Any of the following: established CVD, diabetes, three risk factors for CVD
  • Requiring daily treatment with NSAIDs for arthritis pain
Main exclusion criteria
  • CVD event within 3 months of randomization
Baseline characteristics
  • Average age 63 years
  • Female sex - 64%
  • Arthritis diagnosis: Osteoarthritis - 90% | RA - 10%
  • Established CVD - 23%
  • Average creatinine - 0.9 mg/dl
  • Current aspirin use - 46%
  • Smoker - 21%
Randomized treatment groups
  • Group 1 (8072 patients) - Celecoxib 100 mg twice a day
  • Group 2 (7969 patients) - Naproxen 375 mg twice a day
  • Group 3 (8040 patients) - Ibuprofen 600 mg three times a day
  • Patients with RA could have their doses increased if necessary to 200 mg twice a day for celecoxib, 500 mg twice a day for naproxen, and 800 mg three times a day for ibuprofen
  • Patients with OA could have their naproxen and ibuprofen doses increased, but not celecoxib
  • Esomeprazole 20 - 40 mg was provided to all patients for gastric protection
  • Daily aspirin therapy was permitted
Primary outcome: Composite of first occurrence of an adverse event that met Antiplatelet Trialists Collaboration (APTC) criteria (i.e., death from cardiovascular causes, including hemorrhagic death; nonfatal myocardial infarction; or nonfatal stroke)
Results

Duration: Average of 34 months
Outcome Celecoxib Naproxen Ibuprofen Comparisons
Primary outcome 2.3% 2.5% 2.7% 1 vs 2 p=0.45 | 1 vs 3 p=0.12
Death from cardiovascular causes 0.8% 1.1% 1.0% 1 vs 2 p=0.13 | 1 vs 3 p=0.30
Overall mortality 1.6% 2.0% 1.8% 1 vs 2 p=0.052 | 1 vs 3 p=0.49
Serious gastrointestinal events 1.1% 1.5% 1.6% 1 vs 2 p=0.01 | 1 vs 3 p=0.002
Renal events 0.7% 0.9% 1.1% 1 vs 2 p=0.19 | 1 vs 3 p=0.004
Average daily doses 209 mg 852 mg 2045 mg N/A
  • In the subgroup of patients who were taking daily aspirin, no statistical interaction between naproxen or ibuprofen was found
  • Pain relief was slightly better with naproxen when compared to ibuprofen and celecoxib, but the difference was not considered clinically meaningful
  • In the on-treatment analysis, there was no significant difference between the groups for the primary outcome
  • The average length of time that subjects took their NSAID was 20.3 months. 27% of patients were lost to follow-up during the trial.
  • Adherence to esomeprazole therapy was not measured

Findings: At moderate doses, celecoxib was found to be noninferior to ibuprofen or naproxen with regard to cardiovascular safety


  • Coxibs are COX-2 selective inhibitors. In this study, primarily celecoxib, rofecoxib, etoricoxib, and lumiracoxib.
  • Major vascular event defined as nonfatal myocardial infarction, nonfatal stroke, or vascular death
  • Reference [6]
Annual risk of major vascular event for patients taking select NSAIDs
Drug Annual excess cases per 1000 patients with 2% baseline annual risk Annual excess cases per 1000 patients with 0.5% baseline annual risk
Ibuprofen 800 mg three times a day 9 2
Diclofenac 75 mg twice a day 8 2
Coxibs 7 2
Naproxen 500 mg twice a day -1 0













  • Drugs are typically cleared after 4 - 5 half-lives
  • The manufacturer states that in trials, celecoxib had no effect on reduction of platelet aggregation or increase in bleeding time
  • *The manufacturer states that in trials, nabumetone had little effect on collagen-induced platelet aggregation and no effect on bleeding time
  • References [Manufacturer PI]
NSAID half-lives
Drug Half-life
Ibuprofen (Motrin®, Advil®) 2.2 hours
Naproxen (Aleve®, Anaprox®, etc.) 12 - 17 hours
Meloxicam (Mobic®) 15 - 20 hours
Celecoxib (Celebrex®) 11 hours
Indomethacin (Indocin®) 4.5 hours
Ketorolac (Toradol®) 5 - 6 hours
Nabumetone (Relafen®)* 24 hours













Pricing legend
  • $ = 0 - $50
  • $$ = $51 - $100
  • $$$ = $101 - $150
  • $$$$ = > $151
  • Pricing based on one month of therapy at standard dosing in an adult
  • Pricing based on information from GoodRX.com®
  • Pricing may vary by region and availability