NSAIDs
COX-2 selective NSAIDs
Other NSAID information




Drug Dosage forms Dosing Other
Aspirin

(acetylsalicylic acid)
(ASA)
  • 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
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
Dual antiplatelet therapy (with P2Y12 inhibitor)
  • 81 mg once daily

Children
  • With a few exceptions, aspirin is not recommended in children and teenagers because of the risk of Reye's syndrome
  • See aspirin for a comprehensive review of aspirin including its use in cardiovascular disease and other disease prevention

Price
  • Generic (90 tablets) - $

Drug Dosage forms Dosing Other
Diclofenac Tablet (Cataflam®)
  • 50 mg
  • Diclofenac potassium
Adults  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
  • 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

Price
  • Generic (30 tablets) - $
Tablet, delayed-release (Voltaren®)
  • 25 mg
  • 50 mg
  • 75 mg
  • Diclofenac sodium
  • Tablets are enteric-coated
Adults 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
  • 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.

Price
  • Generic (30 tablets) - $
Tablet, extended-release (Voltaren XR®)
  • 100 mg
  • Diclofenac sodium
Adults 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 XR is diclofenac sodium
  • Voltaren is not bioequivalent with diclofenac potassium on a mg-to-mg basis
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Price
  • Generic (30 tablets) - $
Capsule, liquid filled (Zipsor®)
  • 25 mg
  • Diclofenac potassium
Adults
Mild to moderate acute pain
  • 25 mg four times a day as needed
Other
  • 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.

Price
  • No generic
  • Price (30 capsules) - $$$$
Capsule (Zorvolex®)
  • 18 mg
  • 35 mg
Adults Acute pain
  • 18 - 35 mg three times a day as needed

Osteoarthritis
  • 35 mg three times a day as needed
Other
  • Taking with food may decrease absorption and lower effectiveness
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Price
  • No generic
  • Price (30 capsules) - $$$
Powder for solution (Cambia®)
  • 50 mg packet of powder
  • Comes in box of 9 packets
Adults
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
  • 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.

Price
  • No generic
  • Price (9 packets) - $$$$
Tablet (Arthrotec®)
  • Diclofenac : Misoprostol
    • 50 mg : 200 mcg
    • 75 mg : 200 mcg
Adults 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
  • DO NOT GIVE to pregnant women
  • Misoprostol protects against peptic ulcers
  • Misoprostol may cause diarrhea, abdominal pain, nausea, and flatulence
  • Diclofenac is partially COX-2 selective. See COX selectivity for more.

Price
  • Generic (30 tablets) - $-$$
Patch (Flector®)
  • 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
Adults
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.

Price
  • No generic
  • Price (30 patches) - $$$$
Gel (Voltaren®)
  • 1%
  • Comes in 100 gram tube
Adults
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.

Price
  • Generic (100 grams) - $
Solution (Pennsaid®)
  • 16.05 mg/ml (1.5%)
  • Comes in 150 ml bottle
Adults
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.

Price
  • Generic (150 ml) - $$$

Drug Dosage forms Dosing Other
Diflunisal Tablet (Dolobid®)
  • 500 mg
Adults  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
Price
  • Generic (30 tablets) - $

Drug Dosage forms Dosing Other
Etodolac Capsule (Lodine®)
  • 200 mg
  • 300 mg
Adults 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
  • 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.

Price
  • Generic (30 capsules) - $
Tablet, (Lodine®)
  • 400 mg
  • 500 mg
Adults 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
  • 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.

Price
  • Generic (30 tablets) - $
Tablet, extended-release (Lodine XL®)
  • 400 mg
  • 500 mg
  • 600 mg
Adults Osteoarthritis
  • 400 - 1000 mg once daily as needed
Rheumatoid arthritis
  • 400 - 1000 mg once daily as needed

Children (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
Other
  • Food may increase the rate of absorption. Extent of absorption is not affected.
  • Etodolac is partially COX-2 selective. See COX selectivity for more.

Price
  • Generic (30 tablets) - $-$$

Drug Dosage forms Dosing Other
Fenoprofen Tablet (Nalfon®)
  • 600 mg
Adults 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
  • Taking with food may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.

Price
  • Generic (30 tablets) - $$

Drug Dosage forms Dosing Other
Flurbiprofen Tablet (Ansaid®)
  • 50 mg
  • 100 mg
Adults 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
  • Taking with food may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.

Price
  • Generic (30 tablets) - $

Drug Dosage forms Dosing Other
Ibuprofen Tablet (Motrin®, Advil®)
  • 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)
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

Infants (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


Children (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)
Other
  • Taking after a meal may delay absorption and decrease peak plasma levels. Extent of absorption is not affected.

Price
  • Generic (30 tablets) - $
  • Suspension (120 ml) - $
  • Drops (30 ml) - $
Tablet (Duexis®)
  • Famotidine : Ibuprofen
    • 26.6 mg : 800 mg
Adults Osteoarthritis
  • 1 tablet three times a day as needed

Rheumatoid arthritis
  • 1 tablet three times a day as needed
Other
  • Food may delay absorption
  • Famotidine (Pepcid) is a H2 blocker that may help prevent NSAID-induced peptic ulcers
  • Do not cut or crush tablets

Price
  • No generic
  • Tablets (30) - $$$$

Drug Dosage forms Dosing Other
Indomethacin Capsule (Indocin®)
  • 25 mg
  • 50 mg

Suspension (Indocin®)
  • 25 mg/5 ml
  • Comes in bottles of 237 ml

Suppository (Indocin®)
  • 50 mg
  • Comes in box of 30
Adults 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
  • Suppositories should be refrigerated

Price

Capsule
  • Generic (30 capsules) - $

Suspension
  • No generic
  • 237 ml - $$$$

Suppository
  • No generic
  • 30 supp - $$$$
Capsule, extended-release
(Indocin SR®)
  • 75 mg
Adults 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

Price
  • Generic (30 capsules) - $

Drug Dosage forms Dosing Other
Ketoprofen Capsule (Orudis®)
  • 25 mg
  • 50 mg
  • 75 mg
Adults 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
  • 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

Price
  • Generic (30 capsules) - $
Capsule, extended-release (Oruvail®)
  • 100 mg
  • 150 mg
  • 200 mg
Adults 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
  • 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

Price
  • Generic (30 capsules) - $$$$

Drug Dosage forms Dosing Other
Ketorolac Tablet (Toradol®)
  • 10 mg
Adults 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

Price
  • Generic (30 tablets) - $
Nasal spray (Sprix®)
  • Comes in single-day sprayer that delivers 8 sprays
  • Each spray delivers 15.75 mg of ketorolac
  • Comes in box of 5 sprayers
Adults 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
  • 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.

Price
  • No generic
  • 5 bottles - $$$$

Drug Dosage forms Dosing Other
Meclofenamate Capsule (Meclodium®)
  • 50 mg
  • 100 mg
Adults 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
  • Food decreases the rate and extent of absorption

Price
  • Generic (30 capsules) - $$-$$$$

Drug Dosage forms Dosing Other
Mefenamic acid Capsule (Ponstel®)
  • 250 mg
Adults and adolescents (≥ 14 years) 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
Price
  • Generic (30 capsules) - $$$$

Drug Dosage forms Dosing Other
Meloxicam Tablet (Mobic®)
  • 7.5 mg
  • 15 mg

Suspension (Mobic®)
  • 7.5 mg/5 ml
  • Comes in 100 ml bottle
Adults Osteoarthritis
  • 7.5 - 15 mg once daily
Rheumatoid arthritis
  • 7.5 - 15 mg once daily

Children ≥ 2 years
Juvenile rheumatoid arthritis
  • 0.125 mg/kg once daily
  • Do not exceed 7.5 mg/day
Other
  • May take with or without food
  • Meloxicam is partially COX-2 selective. See COX selectivity for more.

Price
  • Generic (30 tablets) - $
  • Generic (100 ml) - $$
Capsule (Vivlodex®)
  • 5 mg
  • 10 mg
Adults Osteoarthritis
  • 5 - 10 mg once daily
  • Do not exceed 10 mg/day
Other
  • Food may decrease rate of absorption, but extent of absorption is not affected. May take without regard to meals.

Price
  • No generic
  • 30 capsules - $$$$

Drug Dosage forms Dosing Other
Nabumetone Tablet (Relafen®)
  • 500 mg
  • 750 mg
Adults 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
  • May take with or without food
  • Patients who weigh < 50 kg (110 lbs) may respond to lower doses

Price
  • Generic (30 tablets) - $

Drug Dosage forms Dosing Other
Naproxen Naproxen sodium
Tablets, gelcaps, caplets
(Aleve®, Anaprox®)
  • Naproxen : Sodium
    • 200 mg : 20 mg - OTC
    • 250 mg : 25 mg
    • 500 mg : 50 mg

Naproxen
Tablet (Naprosyn®)
  • 250 mg
  • 375 mg
  • 500 mg

Tablet, enteric-coated (EC-Naprosyn®)
  • 375 mg
  • 500 mg

Suspension (Naprosyn®)
  • 25 mg/ml
Adults
Dosing based on naproxen component

Osteoarthritis, Rheumatoid arthritis, Ankylosing spondylitis
  • 250 - 500 mg twice daily as needed
  • Maximum dose is 1500 mg/day

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

Children (≥ 2 years)
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
Other
  • 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

Price
Tablets, gelcaps, caplets
  • Generic (30 tablets) - $

Enteric-coated tablet
  • Generic (30 tablets) - $

Suspension
  • Generic (120 ml) - $
Tablets, extended-release (Naprelan®)
  • 375 mg
  • 500 mg
  • 750 mg
  • Strength based on naproxen component
  • Contains naproxen sodium
Adults
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
  • 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

Price
  • Generic (30 tablets) - $$$$
Tablets, enteric-coated (Vimovo®)
    Naproxen : Esomeprazole
    • 375 mg : 20 mg
    • 500 mg : 20 mg
Adults
Dosing based on naproxen component

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

Price
  • No generic
  • (30 tablets) - $$$$

Drug Dosage forms Dosing Other
Oxaprozin Tablet (Daypro®)
  • 600 mg
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

Children (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
Other
  • Food may decrease the rate of absorption. Extent of absorption is not affected.

Price
  • Generic (30 tablets) - $$

Drug Dosage forms Dosing Other
Piroxicam Capsule (Feldene®)
  • 10 mg
  • 20 mg
Adults 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
  • 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.

Price
  • Generic (30 capsules) - $$

Drug Dosage forms Dosing Other
Sulindac Tablet (Clinoril®)
  • 150 mg
  • 200 mg
Adults 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
  • Take with food

Price
  • Generic (30 tablets) - $

Drug Dosage forms Dosing Other
Tolmetin Tablet (Tolectin®)
  • 200 mg
  • 600 mg

Capsule (Tolectin®)
  • 400 mg
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

Children (≥ 2 years)
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
Other
  • Food decreases bioavailability
  • Do not give with sodium bicarbonate antacids

Price
  • Generic (30 tablets) - $-$$
  • Generic (30 capsules) - $

Drug Dosage forms Dosing Other
Celecoxib Capsule (Celebrex®)
  • 50 mg
  • 100 mg
  • 200 mg
  • 400 mg
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

Children (≥ 2 years)
Juvenile rheumatoid arthritis
  • Weight ≥ 10 kg - ≤ 25 kg: 50 mg twice a day
  • Weight > 25 kg: 100 mg twice a day
Other
  • 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

Price
  • Generic (30 capsules) - $-$$













Annual risk of major vascular event for patients taking select NSAIDs
Medication 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







NSAID side effects
All NSAIDs
  • NOTE: Strength of association is not well-defined

    • Gastrointestinal upset - abdominal pain, heartburn, dyspepsia, nausea, vomiting, constipation, diarrhea
    • Gastrointestinal ulcers - gastric and duodenal
    • Gastritis and esophagitis
    • Gastrointestinal bleeding
    • Decreased kidney function
    • Increased bleeding time
    • Worsening heart failure
    • Increase in blood pressure
    • Tinnitus
    • Dizziness
    • Itching
    • Rashes
    • Elevated liver enzymes


NSAID contraindications/precautions
All NSAIDs
  • Increased risk of thromboembolism - all NSAIDs (except aspirin) may increase the risk of cardiovascular thrombotic events including heart attack and stroke. The risk may be greater with prolonged use. See NSAIDs and cardiovascular risk for more.
  • Coronary Artery Bypass Grafting (CABG) - all NSAIDs (except aspirin) are contraindicated in the perioperative period around CABG surgery. Studies have shown an increased risk of heart attack and stroke in patients who took NSAIDs in the first 10 - 14 days following CABG surgery.
  • Recent myocardial infarction (MI) - observational studies have shown that NSAIDs (excluding aspirin) increase the risk of reinfarction, cardiovascular-related death, and all-cause mortality in patients who have suffered a recent MI. NSAIDs should be avoided in patients with a recent MI unless the benefits outweigh the risks.
  • Gastrointestinal (GI) risk - all NSAIDs increase the risk of gastrointestinal bleeding, ulceration, and perforation. These events can occur at any time during NSAID use. Eighty percent of patients who develop serious upper GI events on NSAIDs are asymptomatic. In patients treated for 3 - 6 months with NSAIDs, 1% will develop serious upper GI events. In patients treated for a year, 2 - 4% will develop serious events. The risk continues to increase with longer durations of use. Patients with a prior history of GI ulcer or bleeding are at greatest risk. Elderly patients are also at increased risk. COX-2 selective NSAIDs (e.g. celecoxib) have a lower risk of GI complications than nonselective NSAIDs. See NSAIDs and peptic ulcers/GI bleeding for more.
  • Hypersensitivity reaction to any NSAID - patients with a history of asthma, urticaria, or other allergic-type reactions to any NSAID may be allergic to all NSAIDs (COX-1 reaction), or they may be allergic to chemically-related NSAIDs. See NSAID allergy for more.
  • Prolonged bleeding - NSAIDs inhibit platelet activation and may prolong bleeding. The effect is greatest with aspirin which irreversibly inhibits platelet function. Other NSAIDs inhibit platelets to a lesser degree, and unlike aspirin, their effect is reversible. COX-2 selective NSAIDs do not inhibit platelets.
  • Asthma - a small subset of asthmatics have "aspirin-exacerbated respiratory disease." These patients may be sensitive to other NSAIDs as well. See NSAID allergy for more.
  • Smoking - smoking can cause gastrointestinal (GI) inflammation and increase the risk for NSAID-induced GI adverse events including ulceration, bleeding, and perforation
  • Elevated liver function tests - borderline elevations (greater than the upper limit of normal [ULN] to 3 X ULN) of liver enzymes may occur in up to 15% of NSAID-treated patients. In trials, severe elevations (> 3 X ULN) have been seen in 1% of NSAID-treated patients. Rare cases of NSAID-induced liver failure have been reported. Patients who develop significant liver disease while taking NSAIDs should discontinue NSAIDs indefinitely.
  • Hypertension - NSAIDs may raise blood pressure through several mechanisms. Patients with uncontrolled hypertension should use caution when taking NSAIDs.
  • Heart failure and edema - NSAIDs may raise blood pressure and promote fluid retention. Patients with heart failure and/or edema should use caution.
  • Kidney disease - long-term NSAID use has been associated with renal papillary necrosis and other kidney diseases. In addition, renal prostaglandins play a compensatory role in maintaining renal perfusion. Prostaglandin inhibition by NSAIDs may decrease renal perfusion and lead to renal decompensation. The risk for NSAID-induced decompensation is greatest in patients with kidney disease, heart failure, liver disease, advanced age, and in those taking diuretics and ACE inhibitors.
  • Serious skin reactions - NSAID use has been associated with serious skin reactions including exfoliative dermatitis, Stevens-Johnson Syndrome (SJS), and toxic epidermal necrolysis (TEN)
  • Pregnancy - NSAIDs should be avoided after 30 weeks of gestation because they may cause premature closure of the ductus arteriosus in the fetus. Safety of use prior to 30 weeks gestation is unknown.
  • Ocular effects - in rare cases, NSAID use has been associated with vision and ocular changes

Diclofenac
  • Bovine protein allergy (Zipsor®) - Zipsor contains gelatin with bovine protein. Do not take if allergic.
  • Phenylketonuria (Cambia®) - Cambia contains aspartame equivalent to phenylalanine 25 mg per packet
  • Pregnancy (Arthrotec®) - misoprostol is contraindicated in pregnancy

Ibuprofen
  • Aseptic meningitis - rare cases of aseptic meningitis have been reported in patients taking ibuprofen. Patients with systemic lupus erythematosus may be at greater risk.

Indomethacin
  • CNS effects - indomethacin may aggravate psychiatric disorders, epilepsy, and parkinsonism. It may also cause drowsiness.

Ketoprofen
  • Kidney disease
    • Mild kidney disease: do not exceed 150 mg/day
    • Severe kidney disease (CrCL < 25 ml/min): do not exceed 100 mg/day
  • Liver disease - ketoprofen is highly protein-bound (> 99%). Starting dose should not exceed 100 mg/day in patients with liver disease or hypoalbuminemia.

Ketorolac
  • Kidney disease - do not use in patients with advanced kidney disease or in patients at risk for kidney failure due to volume depletion

Oxaprozin
  • Photosensitivity - may cause photosensitivity. Avoid sun exposure or wear protection (e.g. sunscreen, clothing)

Sulindac
  • Kidney stones - sulindac metabolites have been found in kidney stones. Use caution in susceptible patients.
  • Pancreatitis - rare cases of pancreatitis have been reported in patients receiving sulindac
  • Aseptic meningitis - sulindac may increase the risk of aseptic meningitis in patients with systemic lupus erythematosus and mixed connective tissue disease

Celecoxib
  • Sulfa allergy - celecoxib contains a sulfonamide group. Patients who are allergic to sulfa drugs may also be allergic celecoxib.
  • CYP2C9 poor metabolizers (e.g. CYP2C9*3/*3) - start therapy at half the recommended daily dose
  • Liver disease
    • Moderate (Child-Pugh B): reduce daily dose by 50%
    • Severe (Child-Pugh C): not recommended

NSAID drug/lab interactions
All NSAIDs
Diclofenac
  • CYP2C9 inhibitors, inducers, and substrates - diclofenac is primarily metabolized by CYP2C9. Inhibitors, inducers, and other substrates of CYP2C9 may alter diclofenac clearance. Diclofenac may affect the clearance of other CYP2C9 substrates.
  • Antacids (Arthrotec®) - Antacids reduce the bioavailability of misoprostol. Magnesium-containing antacids may exacerbate misoprostol-induced diarrhea.
  • Voriconazole - voriconazole may increase blood levels of diclofenac

Diflunisal
  • Acetaminophen - diflunisal may increase blood levels of acetaminophen by up to 50%
  • Antacids - concomitant antacids may reduce diflunisal levels

Etodolac
  • False-positive urinary bilirubin - etodolac may cause false-positive urinary bilirubin on urine dipsticks

Fenoprofen
  • Highly protein-bound drugs - fenoprofen is highly bound to albumin (99%). It may displace other highly protein-bound drugs and vice versa.

Indomethacin
  • Probenecid - probenecid may raise indomethacin levels. Lower indomethacin doses may be appropriate when given with probenecid.

Ketoprofen
  • Probenecid - probenecid reduces ketoprofen clearance and increases levels. They should not be given together.

Ketorolac
  • Probenecid - probenecid reduces ketorolac clearance and increases levels. They should not be given together.
  • Pentoxifylline - ketorolac should not be given with pentoxifylline because of increased risk of bleeding

Meclofenamate
  • Probenecid - probenecid may increase the half-life of meclofenamate. Lower doses of meclofenamate may be necessary.

Mefenamic acid
  • Antacids - magnesium hydroxide antacids may increase absorption of mefenamic acid
  • CYP2C9 inhibitors, inducers, and substrates - mefenamic acid is a substrate of CYP2C9. Inhibitors, inducers and other substrates of CYP2C9 may alter mefenamic acid clearance. Mefenamic acid may affect the clearance of other CYP2C9 substrates.

Meloxicam
  • Sodium polystyrene sulfonate (Kayexalate®) - meloxicam suspension contains sorbitol. It should not be given with Kayexalate because cases of intestinal necrosis have been reported when kayexalate is given with sorbitol.
  • CYP2C9 inhibitors, inducers, and substrates - meloxicam is a substrate of CYP2C9. Inhibitors, inducers and other substrates of CYP2C9 may alter meloxicam clearance. Meloxicam may affect the clearance of other CYP2C9 substrates.

Naproxen
  • Antacids - concomitant antacids may delay the absorption of naproxen
  • Sucralfate - concomitant sucralfate may delay the absorption of naproxen
  • Cholestyramine - concomitant cholestyramine may delay the absorption of naproxen
  • Probenecid - probenecid reduces naproxen clearance and increases levels
  • Highly protein-bound drugs - naproxen is highly protein-bound and may interact with other highly protein-bound drugs
  • Acid-reducing agents (PPI, H2-blocker, etc.) - acid-reducing agents should not be given with enteric-coated naproxen
  • Urinary 17-ketogenic steroids - naproxen may falsely increase urinary values of 17-ketogenic steroids with some assays
  • Urinary 5-hydroxy indoleacetic acid (5HIAA) - naproxen may interfere with some urinary assays of 5HIAA

Oxaprozin
  • Urine drug screens - false-positive urine immunoassay screening tests for benzodiazepines have been reported in patients taking oxaprozin. False-positive results may persist for several days following discontinuation. Confirmatory tests, such as gas chromatography/mass spectrometry, will distinguish oxaprozin from benzodiazepines

Piroxicam
  • Highly protein-bound drugs - piroxicam is highly protein-bound (99%). It may displace other highly protein-bound drugs and vice versa.

Sulindac
  • Probenecid - probenecid may increase levels of sulindac. Sulindac may cause a modest reduction in the uricosuric effect of probenecid.

Tolmetin
  • Urine proteinuria - tolmetin metabolites have been found to give false-positive results for proteinuria on tests which rely on acid precipitation as their endpoint (e.g. sulfosalicylic acid)

Celecoxib
  • CYP2C9 inhibitors, inducers, and substrates - celecoxib is primarily metabolized by CYP2C9. Inhibitors, inducers and other substrates of CYP2C9 may alter celecoxib clearance. Celecoxib may affect the clearance of other CYP2C9 substrates.
  • CYP2D6 substrates - in vitro studies have shown that celecoxib is an inhibitor of CYP2D6. Celecoxib may inhibit the metabolism of CYP2D6 substrates.