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NSAID's

Mechanism of Action -Inhibit prostaglandin synthesis by decreasing the activity of the enzyme, cyclooxygenase, which results in decreased formation of prostaglandin precursors.
Monitoring Parameters:  Monitor CBC, liver enzymes; in patients receiving diuretics, monitor urine output and BUN/serum creatinine.  Patients with renal insufficiency: Baseline renal function followed by repeat test within weeks (to determine if renal function has deteriorated)

Acetic acid derivatives

Arthrotec (diclofenac/misoprostol) diclofenac (Voltaren® Cataflam ®)
Etodolac (Lodine ® ) Indomethacin (Indocin® )
Ketorolac (Toradol ® ) Sulindac (Clinoril ®)
Tolmetin (Tolectin ®)  

Carboxylic acid derivatives

Diflunisal (Dolobid ®) Salsalate (Disalcid ®)

Enolic acid (oxicam) derivatives

Meloxicam (Mobic ® ) piroxicam (Feldene ®)

Napthylkanone derivatives

Nabumetone (Relafen ® )  

Proprionic acid derivatives

Flurbiprofen (Ansaid ® ) Ibuprofen (Motrin ® )
Ketoprofen (Orudis ®) Naproxen (Naprosyn ®)
Oxaprozin (Daypro ® ) Caldolor™ (ibuprofen) Injectionnew icon

COX-2 inhibitors

celecoxib (Celebrex ® ) Rofecoxib (Vioxx ® )
Valdecoxib (Bextra ® )  
Please see package insert for additional information and possible updates. The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material. PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.    [  Read the disclaimer    |   <<Back     ]

Acetic acid derivatives

Arthrotec (diclofenac/ misoprostol): top of page

ARTHROTEC is indicated for treatment of the signs and symptoms of osteoarthritis or rheumatoid arthritis in patients at high risk of developing NSAID-induced gastric and duodenal ulcers and their complications. See WARNINGS, Gastrointestinal Effects - Risk of Ulceration, Bleeding and Perforation for a list of factors that may increase the risk of NSAID-induced gastric and duodenal ulcers and their complications.

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Dosage:
Adults:
Arthrotec® 50:
Osteoarthritis: 1 tablet 2-3 times/day
Rheumatoid arthritis: 1 tablet 3-4 times/day
For both regimens, if not tolerated by patient, the dose may be reduced to 1 tablet twice daily

Arthrotec® 75:
Patients who cannot tolerate full daily Arthrotec® 50 regimens: 1 tablet twice daily
Note: The use of these tablets may not be as effective at preventing GI ulceration

Supplied:
Tablet: Diclofenac sodium 50 mg and misoprostol 200 mcg; diclofenac sodium 75 mg and misoprostol 200 mcg

diclofenac (Voltaren ® Cataflam ®) top of page

Dosing (Adults)
Analgesia/primary dysmenorrhea: Starting dose: 50 mg orally 3 times daily. Maximum dose: 150 mg/day.
Rheumatoid arthritis: 150-200 mg/day orally in 2-4 divided doses (100 mg/day of sustained release product).
Osteoarthritis: 100-150 mg/day orally in 2-3 divided doses (100-200 mg/day of sustained release product).

Supplied:
(Cataflam® - fastest onset of action) 50 mg tablet (K+ salt). (Voltaren®) Delayed release (enteric coated tab - Na+ salt): 25 mg, 50 mg, 75 mg. (Voltaren®-XR) Extended release tab: 100 mg

Maximum Daily Dose:  225 mg;  XR: 200 mg

Etodolac  (Lodine ® ) top of page

Dosing (Adults): Oral:  (May be taken with food to decrease GI distress.)
Acute pain: 200-400 mg every 6-8 hours, as needed, not to exceed total daily doses of 1200 mg; for patients weighing <60 kg, total daily dose should not exceed 20 mg/kg/day

Rheumatoid arthritis, osteoarthritis: Initial: 600-1200 mg/day given in divided doses: 400 mg 2 times/day; 300 mg 2 or 3 times/day; 500 mg 2 times/day; total daily dose should not exceed 1200 mg; for patients weighing <60 kg, total daily dose should not exceed 20 mg/kg/day

Lodine® XL: 400-1000 mg once daily

Supplied:
Capsule (Lodine®): 200 mg, 300 mg
Tablet: 400 mg, 500 mg
Tablet, extended release (Lodine® XL): 400 mg, 500 mg, 600 mg

Maximum Daily Dose::  1200 mg

Indomethacin  (Indocin® ) :  top of page

Indications
Indomethacin has been found effective in active stages of the following:

Moderate to severe rheumatoid arthritis including acute flares of chronic disease.
Moderate to severe ankylosing spondylitis.
Moderate to severe osteoarthritis.
Acute painful shoulder (bursitis and/or tendinitis).
Acute gouty arthritis.


[May cause GI upset, bleeding, ulceration, perforation; take with food or milk to minimize GI upset.]

Dosing (Adults):  25-50 mg/dose 2-3 times/day; maximum dose: 200 mg/day; extended release capsule should be given on a 1-2 times/day schedule; maximum dose for sustained release is 150 mg/day.
Elderly: Refer to Adults dosing; best to start older adults on 25 mg dose given 2-3 times/day

Supplied:
Capsule (Indocin®): 25 mg, 50 mg.
Capsule, sustained release (Indocin® SR): 75 mg.
Injection, powder for reconstitution, as sodium trihydrate (Indocin® I.V.): 1 mg
Suspension, oral (Indocin®): 25 mg/5 mL (237 mL).

Maximum Daily Dose: 200 mg;   SR: 150mg

Ketorolac  (Toradol ® ) top of page

Dosing (Adults):  Pain (acute; moderately-severe):

Note: The maximum combined duration of treatment (for parenteral and oral) is 5 days - do not increase dose or frequency.

IM: 60 mg x 1 or 30 mg q6h (maximum daily dose: 120 mg).
 IV: 30 mg x 1 or 30 mg q6h (maximum daily dose: 120 mg).

Oral
: 20 mg, followed by 10 mg every 4 to 6 hours (Max 40 mg/day). Oral dosing is intended to be a continuation of IM/IV therapy only.

Dosing (EXCEPTIONS): Elderly (>65 yo - elderly pts have increased incidence of GI bleeding, ulceration, and perforation. Also decreased clearance), Renal insufficiency or weight <50 kg:
IM: 30 mg x1 or 15 mg q6h (maximum daily dose: 60 mg) IV: 15 mg x 1 or 15mg q6h (maximum daily dose: 60 mg) Oral: 10 mg every 4-6 hours (max 40 mg/day).

Renal dosing: Do not use in patients with advanced renal impairment. Patients with moderately-elevated serum creatinine should use half the recommended dose, not to exceed 60 mg/day IM/IV.


Maximum Daily Dose:  IV/ IM:120 mg;   oral: 40mg

Sulindac  (Clinoril ®)  top of page

Indications
Carefully consider the potential benefits and risks of CLINORIL and other treatment options before deciding to use CLINORIL. Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals.

CLINORIL is indicated for acute or long-term use in the relief of signs and symptoms of the following:

Osteoarthritis
Rheumatoid arthritis**
Ankylosing spondylitis
Acute painful shoulder (Acute subacromial bursitis/supraspinatus tendinitis)
Acute gouty arthritis
** The safety and effectiveness of CLINORIL have not been established in rheumatoid arthritis patients who are designated in the American Rheumatism Association classification as Functional Class IV (incapacitated, largely or wholly bedridden, or confined to wheelchair; little or no self-care).

Dosage:
Adults: 150-200 mg twice daily or 300-400 mg once daily; not to exceed 400 mg/day.
[Should be administered with food or milk.]

Supplied:
Tablet: 150 mg, 200 mg

Maximum Daily Dose :  400 mg

Tolmetin  (Tolectin ®)  top of page

Use
Treatment of rheumatoid arthritis and osteoarthritis, juvenile rheumatoid arthritis

Dosage:
Osteoarthritis and Rheumatoid Arthriti (Adult ): initial, 400 mg orally three times a day for 1-2 weeks. Maintenance:
200 to 600 mg orally three times a day. Maximum: 1800 mg/day.

Supplied:
400 mg capsule. 200, 600 mg tab]

Maximum Daily  Dose
1800 mg

Carboxylic acid derivatives

Diflunisal (Dolobid ®)  top of page

Use
Management of inflammatory disorders usually including rheumatoid arthritis and osteoarthritis; can be used as an analgesic for treatment of mild to moderate pain.

Administration
Tablet should be swallowed whole; do not crush or chew.
Should be taken with food to decrease GI distress.

Dosage:
Adults: Oral:
Osteoarthritis: 500-750 mg/day in divided doses.
Pain: Initial: 500-1000 mg followed by 250-500 mg every 8-12 hours; maximum daily dose: 1.5 g
 Inflammatory condition: 500-1000 mg/day in 2 divided doses; maximum daily dose: 1.5 g

Dosing adjustment in renal impairment: Clcr<50 mL/minute: Administer 50% of normal dose.

Supplied:
Tablet: 250 mg, 500 mg

Salsalate  (Disalcid ®)  top of page

Dosing (Adults):  3000 mg/day divided every 8 to 12 hours.

Dosing comments in renal impairment: In patients with end-stage renal disease undergoing hemodialysis: 750 mg twice daily with an additional 500 mg after dialysis

Supplied:
Tablet: 500 mg, 750 mg

Enolic acid (oxicam) derivatives

Meloxicam  (Mobic ® ) top of page

Use
Relief of signs and symptoms of osteoarthritis and rheumatoid arthritis
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Dosage:
Adults: Oral: Initial: 7.5 mg once daily; some patients may receive additional benefit from an increased dose of 15 mg once daily; maximum dose: 15 mg/day
Elderly: Increased concentrations may occur in elderly patients (particularly in females); however, no specific dosage adjustment is recommended
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Dosage adjustment in renal impairment:
Mild to moderate impairment: No specific dosage recommendations.
Significant impairment (Clcr </= 15 mL/minute): Avoid use.

Supplied:
Suspension: 7.5 mg/5 mL (100 mL)
Tablet: 7.5 mg, 15 mg

Maximum Daily Dose :  15 mg

piroxicam (Feldene ®)  top of page

Use
Symptomatic treatment of acute and chronic rheumatoid arthritis and osteoarthritis.

Dosage:
Adults: 10-20 mg/day once daily; although associated with increase in GI adverse effects, doses >20 mg/day have been used (ie, 30-40 mg/day). May be taken with food to decrease GI adverse effect.
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Dosing adjustment in hepatic impairment: Reduction of dosage is necessary
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Monitoring Parameters
Occult blood loss, hemoglobin, hematocrit, and periodic renal and hepatic function tests; periodic ophthalmologic exams with chronic use
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Supplied:
Capsule: 10 mg, 20 mg

Maximum Daily Dose :  20 mg

Napthylkanone derivatives

Nabumetone  (Relafen ® ) top of page

Dosing (Adults)
Initial: 1000 mg orally with or without food. Some patients may obtain more symptomatic relief from 1500 mg to 2000 mg per day (in two divided doses). Dosages over 2000 mg per day have not been studied.
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Use
Management of osteoarthritis and rheumatoid arthritis
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Supplied:
Tablet: 500 mg, 750 mg

Maximum Daily Dose:  2000 mg

Proprionic acid derivatives

Flurbiprofen  (Ansaid ® ) top of page

Dosing (Adults): 200-300 mg/day in 2 to 4 divided doses.  Do not administer more than 100 mg for any single dose; maximum: 300 mg/day.
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Use
Oral: Treatment of rheumatoid arthritis and osteoarthritis
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Supplied:
Tablet (Ansaid®): 50 mg, 100 mg

Maximum Daily Dose:  300 mg

Ibuprofen  (Motrin ® ) top of page

See also Caldolor™ (ibuprofen) Injection

Carefully consider the potential benefits and risks of MOTRIN tablets and other treatment options before deciding to use MOTRIN. Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals.

MOTRIN tablets are indicated for relief of the signs and symptoms of rheumatoid arthritis and osteoarthritis.

MOTRIN tablets are indicated for relief of mild to moderate pain.

MOTRIN tablets are also indicated for the treatment of primary dysmenorrhea.

Controlled clinical trials to establish the safety and effectiveness of MOTRIN tablets in children have not been conducted.

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Dosage:  [Administer with food ]
Oral:
Children:
Antipyretic: 6 months to 12 years: Temperature <102.5°F (39°C): 5 mg/kg/dose; temperature >102.5°F: 10 mg/kg/dose given every 6-8 hours (maximum daily dose: 40 mg/kg/day)

Juvenile rheumatoid arthritis: 30-50 mg/kg/24 hours divided every 8 hours; start at lower end of dosing range and titrate upward (maximum: 2.4 g/day)

Analgesic: 4-10 mg/kg/dose every 6-8 hours

OTC labeling (analgesic, antipyretic):
Children 6 months to 11 years: See table; use of weight to select dose is preferred; doses may be repeated every 6-8 hours (maximum: 4 doses/day)
Weight
(lb)
Age Dosage
(mg)
12-17 6-11 mo 50
18-23 12-23 mo 75
24-35 2-3 y 100
35-47 4-5 y 150
48-59 6-8 y 200
60-71 9-10 y 250
72-95 11 y 300


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Children >/= 12 years: 200 mg every 4-6 hours as needed (maximum: 1200 mg/24 hours)
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Adults:
Inflammatory disease: 400-800 mg/dose 3-4 times/day (maximum dose: 3200 mg/day)

Analgesia/pain/fever/dysmenorrhea: 200-400 mg/dose every 4-6 hours (maximum daily dose: 1.2 g, unless directed by physician)

OTC labeling (analgesic, antipyretic): 200 mg every 4-6 hours as needed (maximum: 1200 mg/24 hours)

Dosing adjustment/comments in severe hepatic impairment: Avoid use

Supplied:
Caplet: 200 mg
Capsule, liqui-gel: 200 mg
Gelcap: Advil®: 200 mg
Suspension, oral: 100 mg/5 mL (5 mL, 120 mL, 480 mL)
Suspension, oral drops: 40 mg/mL (15 mL)
Tablet: 200 mg, 400 mg, 600 mg, 800 mg
     Advil® Junior: 100 mg
Tablet, chewable: 50 mg, 100 mg

Ketoprofen  (Orudis ®) top of page

Use
Acute and long-term treatment of rheumatoid arthritis and osteoarthritis; primary dysmenorrhea; mild to moderate pain
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Dosage:  In order to minimize gastrointestinal effects, ketoprofen can be prescribed to be taken with food or milk.
Oral:  Children >/= 16 years and Adults:
Rheumatoid arthritis or osteoarthritis:
Capsule: 50-75 mg 3-4 times/day up to a maximum of 300 mg/day.
Capsule, extended release: 200 mg once daily.

Mild to moderate pain: Capsule: 25-50 mg every 6-8 hours up to a maximum of 300 mg/day

OTC labeling: 12.5 mg every 4-6 hours, up to a maximum of 6 tablets/24 hours
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Elderly: Initial dose should be decreased in patients >75 years; use caution when dosage changes are made
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Dosage adjustment in renal impairment:
Mild impairment: Maximum dose: 150 mg/day
Severe impairment: Maximum dose: 100 mg/day
Dosage adjustment in hepatic impairment and serum albumin <3.5 g/dL: Maximum dose: 100 mg/day.

Supplied:
Capsule: 50 mg, 75 mg
Capsule, extended release (Oruvail®): 100 mg, 150 mg, 200 mg
Tablet (Orudis® KT): 12.5 mg

Naproxen  (Naprosyn ®) top of page

Dosing (Adults):
Rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis: 250-500 mg orally twice daily. May increase to 1.5 g/day of naproxen base for limited time period. Acute gout: Initial: 750 mg x 1, followed by 250 mg every 8 hours until attack subsides.

Mild-to-moderate pain, dysmenorrhea, acute tendonitis, bursitis: Initial: 500 mg x 1, then 250 mg every 6 to 8 hours. (Controlled release tablet): 375 to 1000 mg orally once daily.
Important Note: EC-Naprosyn® has an enteric coating that delays absorption (longer onset of action), and therefore should not be used for acute pain (e.g. gout attack).

Supplied:  Tablet: 250 mg, 375 mg, 500 mg. Caplet/Gelcap: 220 mg (Na+ salt - equivalent to 200mg tablet - OTC). Suspension: 125 mg/5 ml.
Tablet (sodium salt) Anaprox ®: 220mg, 275 mg, 550mg. Tablet (controlled release - Na+ salt): 421.5 mg, 550 mg. Tablet (delayed release) - EC-Naprosyn®: 375 mg, 500 mg.
Dosage form Peak plasma level
Naproxen sodium 1 to 2 hours
Naproxen base 2 to 4 hours
Naproxen (EC)  4 to 6 hours

Maximum Daily Dose:  1375 mg max

Oxaprozin  (Daypro ® ) top of page

Carefully consider the potential benefits and risks of DAYPRO and other treatment options before deciding to use DAYPRO. Use the lowest effec- tive dose for the shortest duration consistent with individual patient treatment goals. DAYPRO is indicated:

For relief of the signs and symptoms of osteoarthritis
For relief of the signs and symptoms of rheumatoid arthritis
For relief of the signs and symptoms of juvenile rheumatoid arthritis
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Dosage:
Adults:
Osteoarthritis: 600-1200 mg once daily; patients should be titrated to lowest dose possible; patients with low body weight should start with 600 mg daily

Rheumatoid arthritis: 1200 mg once daily; a one-time loading dose of up to 1800 mg/day or 26 mg/kg (whichever is lower) may be given

Maximum daily dose: 1800 mg or 26 mg/kg (whichever is lower) in divided doses
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Dosing adjustment in renal impairment: 600 mg once daily; dose may be increased to 1200 mg with close monitoring
Dosing adjustment in hepatic impairment: Use caution in patients with severe dysfunction
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Supplied:
Tablet: 600 mg

COX-2 inhibitors

celecoxib  (Celebrex ® )  top of page

Carefully consider the potential benefits and risks of Celebrex and other treatment options before deciding to use Celebrex. Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals.

Osteoarthritis (OA)
Celebrex is indicated for relief of the signs and symptoms of OA

Rheumatoid Arthritis (RA)
Celebrex is indicated for relief of the signs and symptoms of RA

Juvenile Rheumatoid Arthritis (JRA)
Celebrex is indicated for relief of the signs and symptoms of JRA in patients 2 years and older

Ankylosing Spondylitis (AS)
Celebrex is indicated for the relief of signs and symptoms of AS

Acute Pain (AP)
Celebrex is indicated for the management of AP in adults

Primary Dysmenorrhea (PD)
Celebrex is indicated for the treatment of PD

Familial Adenomatous Polyposis (FAP)
Celebrex is indicated to reduce the number of adenomatous colorectal polyps in FAP, as an adjunct to usual care (e.g., endoscopic surveillance, surgery). It is not known whether there is a clinical benefit from a reduction in the number of colorectal polyps in FAP patients. It is also not known whether the effects of Celebrex treatment will persist after Celebrex is discontinued. The efficacy and safety of Celebrex treatment in patients with FAP beyond six months have not been studied.

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Dosage:
Adults: Oral:
Acute pain or primary dysmenorrhea: Initial dose: 400 mg, followed by an additional 200 mg if needed on day 1; maintenance dose: 200 mg twice daily as needed

Osteoarthritis: 200 mg/day as a single dose or in divided dose twice daily

Rheumatoid arthritis: 100-200 mg twice daily
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Elderly: No specific adjustment is recommended. However, the AUC in elderly patients may be increased by 50% as compared to younger subjects. Use the lowest recommended dose in patients weighing <50 kg.
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Dosing adjustment in renal impairment: No specific dosage adjustment is recommended; not recommended in patients with advanced renal disease

Dosing adjustment in hepatic impairment: Reduced dosage is recommended (AUC may be increased by 40% to 180%); decrease dose by 50% in patients with moderate hepatic impairment (Child-Pugh Class II)
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Supplied:
Capsule: 100 mg, 200 mg, 400 mg

Rofecoxib  (Vioxx ® )  top of page

No longer manufactured - DISCONTINUED.:

Osteoarthritis: 12.5 mg once daily; may be increased to a maximum of 25 mg once daily
Acute pain
: 50 mg orally once daily.

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Supplied:
Tablet: 12.5 mg, 25 mg, 50 mg

Valdecoxib  (Bextra ® )  top of page

Relief of signs and symptoms of osteoarthritis and adult rheumatoid arthritis; treatment of primary dysmenorrhea
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Dosage:
Oral: Adults:
Osteoarthritis and rheumatoid arthritis: 10 mg once daily; Note: No additional benefits seen with 20 mg/day

Primary dysmenorrhea: 20 mg twice daily as needed
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Dosage adjustment in renal impairment: Not recommended for use in advanced disease

Dosage adjustment in hepatic impairment: Not recommended for use in advanced liver dysfunction (Child-Pugh Class C)
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Supplied:
Tablet: 10 mg, 20 mg

Disclaimer

Listed dosages are for - Adult patients ONLY. PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER. GlobalRPH does not directly or indirectly practice medicine or provide medical services and therefore assumes no liability whatsoever of any kind for the information and data accessed through the Service or for any diagnosis or treatment made in reliance thereon.

David F. McAuley, Pharm.D., R.Ph.  GlobalRPh Inc.
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