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
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

- YES/$$$$

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 IR (Tivorbex®)

Dosage forms

Capsule
  • 20 mg

Dosing

Mild to moderate acute pain in adults
  • Dosing: 20 mg three times daily or 40 mg two to three times daily

Other

  • Not interchangeable with other formulations of indomethacin
  • Taking with food decreases the rate of absorption but not the extent

Generic / Price

- YES/$$$$

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

- YES/$$$$

Naproxen + Sumatriptan (Treximet®)

Dosage forms

Tablets
  • Sumatriptan : Naproxen sodium
    • 85 mg : 500 mg

Dosing

Migraine headache
  • Initial: 1 tablet (85/500)
  • May repeat one time in 2 hours if needed
  • Do not exceed 2 tablets in 24 hours
  • May take without regard to food

Other


Generic / Price

- YES/$$$$ (9 tablets)

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 (adults and children ≥ 12 years)
  • 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 can cause maternal and fetal harm, including uterine rupture, abortion, premature birth, and birth defects.
  • 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 epolamine
  • Comes in box of 30 patches

Dosing

Local acute pain due to strains, sprains, and contusions
  • Apply 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 (Licart®)

Dosage forms

Patch
  • 1.3% patch
  • Patch is 10 X 14 cm (3.9" X 5.5")
  • Comes in box with 15 patches
  • Licart is diclofenac epolamine

Dosing

Local acute pain due to minor strains, sprains, and contusions
  • Apply 1 patch to most painful area once daily

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/$$$$ (15 patches)

Diclofenac (Pennsaid®)

Dosage forms

1.5% solution
  • 16.05 mg/ml (1.5%)
  • Comes in 150 ml bottle
2% solution
  • 20 mg/g (2%)
  • Comes in 112 g pump

Dosing

Osteoarthritis of the knee
  • 1.5% solution
    • Apply 40 drops on each painful knee 4 times a day as needed
    • To avoid spillage, dispense 10 drops at a time either directly onto the knee or first into the hand and then onto the knee. Spread solution evenly around the front, back, and sides of the knee. Repeat this procedure until 40 drops have been applied and the knee is completely covered with solution.
  • 2% solution
    • Apply 40 mg of diclofenac sodium (2 pump actuations) on each painful knee 2 times a day as needed
    • Deliver the product directly into the palm of the hand and then apply evenly around the front, back, and sides of the knee
    • Each pump actuation delivers 20 mg of diclofenac sodium in 1 gram of solution

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

  • 1.5% solution: YES/$
  • 2% solution: NO/$$$$

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

- YES/$$$$ (#30)

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
Liver disease
  • Child-Pugh A: no adjustment necessary
  • Child-Pugh B: reduce dose by 50%
  • Child-Pugh C: not recommended
Poor CYP2C9 metabolizers
  • Initiate treatment with half of the lowest recommended dose

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)

Celecoxib liquid (Elyxyb®)

Dosage forms

Liquid
  • 120 mg/4.8 ml (25 mg/ml) glass bottle
  • Comes in carton with 6 bottles
  • Store at room temp

Dosing (Adults)

Acute migraine with or without aura
  • Dosing: 120 mg (1 bottle) per 24 hour period
  • Do not exceed 120 mg in a 24-hour period
  • May take without regard to food
Liver disease
  • Child-Pugh A: no adjustment necessary
  • Child-Pugh B: 60 mg (2.4 ml) per 24 hour period
  • Child-Pugh C: not recommended
Poor CYP2C9 metabolizers
  • 60 mg (2.4 ml) per 24 hour period

Efficacy


Other

  • Time to max level: 1 hour
  • Half-life: 6 hours
  • The manufacturer states that in trials, celecoxib had no effect on reduction of platelet aggregation or increase in bleeding time
  • Celecoxib is a COX-2 selective NSAID

Generic / Price

- NO/$$$$ (6 bottles)

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/$$$$

Seglentis® (celecoxib + tramadol)

Dosage forms

Tablet
  • Celecoxib - Tramadol
    • 56 mg - 44 mg

Dosing

Acute pain
  • Dosing: 2 tablets every 12 hours as needed
  • May take without regard to food
  • Tramadol is an opiate medication. See tramadol for more.

Generic / Price

- NO/$$$ for #30












  • 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
  • No antiplatelet activity. Does not need to be held.
  • *The manufacturer states that in trials, nabumetone had little effect on collagen-induced platelet aggregation and no effect on bleeding time
  • ‡ At a daily dose of 7.5 mg, it is relatively COX-2 selective and could be continued in the absence of high bleeding risk surgery
  • References [Manufacturer PI, 14]
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
Etodolac (Lodine®) 7 - 11 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