Knee pain/NSAIDs

[Bluntschli]

Jordan,

My oldest recently started working as a waitress. Prior to that she was pretty inactive - a fair amount of walking around campus but no additional exercise. 20yo, carrying extra weight but not morbidly obese. She went through the expected phase of foot pain and is pretty much past that, but now says that her knees hurt, and she has limited range of motion (she says she can't fully straighten one leg.

Question 1: Does this sound like inflammation, something that ibuprofen would help? If so, as the amount of standing/walking isn't going away, would you expect her to have to take ibuprofen indefinitely?

Question 2: She is under the impression that taking NSAIDs increases risk of stroke and heart attack. I know from its constant recommendation here (on this site in general) that it probably does not, but I don't know why. I'm not asking for citations, but is this just a case of bad science/research?

Finally, if this question is overstepping (ie if you feel like I'm asking for personal medical advice) then I totally understand if you just delete. It feels like rehab territory to me, which is a pretty common topic around here, which is why I feel okay asking.

Thanks.

[Jordan Feigenbaum]

1) Hard to say without seeing it, but inflammation is likely regardless of the root cause. Might be an underlying injury or maybe not. I would expect her to get used to the imposed demands and adapt, thereby not requiring full time intervention. If something is injured, however, this may be a different story.

2) She is right, there is a small cardiac risk by taking NSAIDs other than naproxen. It's usually a non factor for short term use (< 1 month) but it is in the literature for sure. I'd use Naproxen, if possible.

[Bluntschli]

Perfect, thanks. Would the 3200mg daily of Ibuprofen I've read about elsewhere on the site be an appropriate amount for Naproxen as well?

[Sean Herbison]

2) She is right, there is a small cardiac risk by taking NSAIDs other than naproxen. It's usually a non factor for short term use (< 1 month) but it is in the literature for sure. I'd use Naproxen, if possible.

To do a small hi-jack, the exception for Naproxen (which I did not know about) only applies to cardiac risk, correct? I.e. the stomach risk is a separate issue, and still applicable with Naproxen?

[Jordan Feigenbaum]

Perfect, thanks. Would the 3200mg daily of Ibuprofen I've read about elsewhere on the site be an appropriate amount for Naproxen as well?

No. Sorry for not clearing that up. Max dose is ~1250mg IIRC.

To do a small hi-jack, the exception for Naproxen (which I did not know about) only applies to cardiac risk, correct? I.e. the stomach risk is a separate issue, and still applicable with Naproxen?

Correct.

[Subsistence]

It isn't fair to say there is no cardiovascular risk for naproxen, just that it is the lowest risk out of the NSAIDs.

[Jordan Feigenbaum]

It isn't fair to say there is no cardiovascular risk for naproxen, just that it is the lowest risk out of the NSAIDs.

I do not agree with this. The compiled data show NO increased risk compared to placebo from Naproxen for major cardiovascular or coronary events in those with or without pre existing cardiovascular disease. None.

[Paul1]

There are MANY pooled studies / meta-analyses as well as high quality individual trials; and there is enough disagreement among them that I cannot responsibly conclude that the risk with naproxen is no different than placebo. I'm not saying I can responsibly conclude the opposite either -- but the fact is that many studies show it's got increased risk; and since increased risk appears to be a class effect of NSAIDs it's more likely that unmeasured differences in naproxen use or in study design account for all the heterogeneity in study findings.

Select studies:

In a study of 93,000 patients naproxen had a significantly increased risk of cardiovascular death compared with placebo: HR 1.27[1.01-1.59] -- its risk was lower than ibuprofen, but it was significantly elevated compared with no NSAID.
PLoS One. 2013;8(1):e54309

WHI study in which more than 53,000 patients had regular NSAID use, naproxen had a hazard ratio for cardiovascular events of 1.22 (1.12-1.34; P<0.001) and was the ONLY nonselective COX inhibitor in which this was found.
Circ Cardiovasc Qual Outcomes. 2014 Jul;7(4):603-10

In 41 pooled studies COX-2 inhibitors had markedly increased hazard ratio compared with placebo, but when directly compared there was no significant difference between celecoxib and naproxen. (This study did not report naproxen vs placebo).
Minerva Cardioangiol. 2014 Dec;62(6):437-48. Epub 2014 Jul 16

An interesting study pooled acute MI / GI bleeding hospitalization risk, and found that naproxen conferred the highest risk of AMI/GIB hospitalization, even compared with COX-2 inhibitors in which the GIB risk was lowered. The odds ratio of AMI for all NSAIDs crossed 1 (except for rofecoxib whose lower OR range was 1.00) compared with acetaminophen -- meaning that none of them had a demonstrably different MI rate than one another, but naproxen had the GI bleed risk as well.
Rheumatology (Oxford). 2007 Mar;46(3):435-8

Also, naproxen in one metaanalysis had a significantly higher risk of stroke than the COX-2 inhibitor rofecoxib.
Ther Adv Musculoskelet Dis. 2014 Aug;6(4):111-30.

[Hyperfluxe]

Is it bad to regularly use Naproxen to treat golfers/tennis elbow?

[Subsistence]

I do not agree with this. The compiled data show NO increased risk compared to placebo from Naproxen for major cardiovascular or coronary events in those with or without pre existing cardiovascular disease. None.

http://circoutcomes.ahajournals.org/...00800.abstract

http://www.medscape.com/viewarticle/820470

To claim with confidence that naproxen has no risk seems to in the very least overreach the current position of the medical community.