Step 1 Nonopioid Analgesics
| Drug (Brand name) Rx or OTC | Usual Starting Dose | Maximum Daily Dose | Comments | Cost/day* |
|---|---|---|---|---|
| Acetaminophen (Tylenol, others) OTC | 650 mg q4–6 hours | 4000 mg | 1000 mg is more effective than 650 mg in some patients | <$1.00 |
| Aspirin (various) OTC | 650 mg q4–6 hours | 4000 mg | May not be tolerated as well as some newer NSAIDs. | <$1.00 |
| Diflunisal (Dolobid) Rx | 1000 mg ×1 then 500 mg q12 hours | 1500 mg | Derived from salicylic acid. Little antipyretic activity | $2.80 |
| Nonacetylated Salicylates | ||||
| Choline magnesium trisalicylate (Trilisate, others) Rx | 1500 mg ×1 then 1000 mg q12 hours | 3000 mg | Effective anti-inflammatory drugs, but less effective analgesics than aspirin. Have minimal antiplatelet effect and do not alter bleeding time. Aspirin cross-sensitivity less likely to occur. | $3.00 |
| Salsalate (Disalcid, others) Rx | 1500 mg ×1 then 1000 mg q12 hours | 3000 mg | $2.50 | |
| Other NSAIDs: Propionic Acid | ||||
| Fenoprofen (Nalfon, others) Rx | 200 mg q4–6 hours | 1200 mg | 90% eliminated by the kidney. | $3.40 |
| Flurbiprofen (Ansaid, others) Rx | 50 mg q8–12 hours | 300 mg | At high doses, monitor closely for side effects. | $1.00 |
| Ibuprofen (Rx: Motrin, others; OTC: Advil, Nuprin, others) | 400 mg q4–6 hours; OTC use: 200–400 mg q4–6 hours | 2400 mg; OTC 1200 mg | 200 mg ≈ 650 mg aspirin or APAP. 400 mg ≈ codeine/APAP | $1.60 |
| Ketoprofen (Rx: Orudis, others; OTC: Actron, Orudis-KT) | 25–50 mg q6–8 hours; OTC use: 12.5–25 mg q4–6 hours | 300 mg; OTC 75 mg | 12.5 mg ≈ 200 mg ibuprofen; 50 mg superior to codeine/APAP | $3.60 |
| Naproxen (Naprosyn, others) Rx | 500 mg ×1 then 500 mg q12 hours or 250 mg q6–8 hours | 1250 mg first day then 1000 mg | 250 mg ≈ 650 mg aspirin with longer duration. 95% eliminated by the kidney. | <$1.00 |
| Naproxen sodium (Rx: Anaprox, others; OTC: Aleve, others) | 550 mg ×1 then 550 mg q12 hours or 275 mg q6–8 hours; OTC use: 220–440 mg ×1 then 220 mg q8–12 hours | 1375 mg first day then 1100 mg; OTC 660 mg | 275 mg ≈ 650 mg aspirin with longer duration; OTC 440 mg ≈ 400 mg ibuprofen. 95% eliminated by the kidney. Naproxen sodium may have less dyspepsia than naproxen | <$1.00 |
| Oxaprozin (Daypro) Rx | 600–1200 mg qd | 1800 mg | Long serum half-life (42–50 hours) | $1.66 |
| Other NSAIDs: Acetic Acid | ||||
| Diclofenac potassium (Cataflam, others) Rx | 50 mg q8 hours or 75 mg bid | 150 mg | May have less dyspepsia than the sodium salt. | $1.10 |
| Diclofenac sodium (Voltaren, others; extended-release: Voltaren XR, others) Rx | 50 mg q8 hours or 75 mg bid; extended-release 100 mg qd | 150 mg; for Voltaren XR 100 mg | Also available with misoprostol 200 μg (Arthrotec 50 mg, 75 mg) to decrease GI toxicity. | $1.00 |
| Etodolac (Lodine, others; extended-release: Lodine XL) Rx | 200–400 mg q6–8 hours; Lodine XL 400 mg qd | 1200 mg; for Lodine XL 1000 mg | 200 mg ≈ 650 mg aspirin or APAP | $2.70 |
| Indomethacin (Indocin, other; sustained release: Indocin SR, others) Rx | 25 mg q8–12 hours; sustained release 75 mg qd | 200 mg; for Indocin SR 75 mg bid | Higher incidence of side effects. Also available in oral suspension. | <$1.00 |
| Ketorolac (Toradol) | 10 mg q4–6 hours | 40 mg | 91% eliminated by the kidney. Use lower dose if >65 years or <50kg. Do not use >5 days | $3.70 |
| Sulindac (Clinoril, others) Rx | 150–200 mg bid | 400 mg | Have few cases reporting less drug interaction with lithium | <$1.00 |
| Tolmetin (Tolectin, others;) Rx | 200–600 tid | 1800 mg | 100% eliminated by the kidney. | $1.65 |
| Other NSAIDs: Fenamates | ||||
| Meclofenamate (various) Rx | 50–100 mg q4–6 hours | 400 mg | Comparable with aspirin. Commonly used for dysmenorrhea. Diarrhea is common | $1.10 |
| Mefenamic acid (Ponstel) Rx | 500 mg ×1 then 250 mg q6 hours | 1250 mg | Effective in dysmenorrhea. Do not use >1 week | $5.20 |
| Other NSAIDs: Naphthylalkanone | ||||
| Nabumetone (Relafen) Rx | 1000 mg qd | 2000 mg | Can be given either qd or bid | $2.40 |
| Other NSAIDs: Oxicam | ||||
| Meloxicam (Mobic) Rx | 7.5 mg qd | 15 mg | Dose-dependent COX-2/COX-1 inhibition | $2.00 |
| Piroxicam (Feldene, others) Rx | 20 mg qd | 20 mg | Long serum half-life (50 hours). High incidence of side effects, especially in the elderly. | <$1.00 |
| COX-2 Inhibitors | ||||
| Celecoxib (Celebrex) Rx | Acute pain: 400–600 mg first day, then 200 mg bid | 400 mg | Contraindicated in sulfa allergy | $4.70 |
| Valdecoxib (Bextra) Rx | Dysmenorrhea: 20 mg bid | 40 mg | Approved for osteoarthritis/rheumatoid arthritis and dysmenorrhea only | $5.40 |
| Injectable NSAIDs | ||||
| Ketorolac IV/IM (Toradol) Rx | <65 years: 60 mg ×1 then 30 mg q6 hours; ≥65 years: 30 mg ×1 then 15 mg q6 hours | 120 mg | 91% eliminated by the kidney. Use lower dose if >65 or <50kg. Do not use >5 days | $7.99 ea dose |
* Cost/day = cost of usual daily dosage based on price listing at www.drugstore.com on 2003 Oct 21. Generic drugs were used whenever available.
qid, 4 times per day; tid, 3 times per day; bid, twice per day; qd, once per day; q, every.