Management of Shoulder Pain

Introduction to Naproxen Treatment

• The American Gastroenterological Association recommends considering the addition of a proton pump inhibitor for patients with increased GI risk when taking naproxen, to minimize adverse effects 1
• The American Heart Association suggests using the lowest effective dose of naproxen for the shortest duration possible, as all NSAIDs carry cardiovascular risk 2
• The American College of Rheumatology recommends considering topical NSAIDs as a safer alternative for elderly patients (≥75 years) with localized shoulder pain 3

Safety Factors and Contraindications

• Patients with a history of peptic ulcer disease, elderly patients, and those with concomitant use of corticosteroids or anticoagulants are at higher risk for GI complications when taking naproxen 1
• The use of naproxen may increase cardiovascular risk, and patients with cardiovascular disease should use the lowest effective dose for the shortest duration possible 2
• Patients with renal impairment should use naproxen with caution, as dosage adjustment may be necessary 1
• Risk factors for GI complications include advanced age, history of peptic ulcer disease, concomitant use of corticosteroids or anticoagulants, and higher doses and longer duration of treatment 4
• All NSAIDs carry cardiovascular (CV) risk, but short-acting formulations allow for more flexible dosing and drug-free intervals, which may reduce this risk 5

Treatment Approaches

• For patients with GI risk factors, adding a proton pump inhibitor to naproxen treatment is recommended 1
• For patients with CV risk factors, using the lowest effective dose (250 mg twice daily) or alternative analgesics is recommended 2
• For inadequate response to naproxen treatment, reassess and consider alternative treatments such as physical therapy, corticosteroid injections, or referral to specialist after 2-4 weeks 3
• The first-line approach for localized shoulder pain is topical NSAIDs, which have the best safety profile, as recommended by the European League Against Rheumatism (EULAR) guidelines 4
• The second-line approach is paracetamol (acetaminophen) up to 4g/day, which has a relatively favorable safety profile despite uncertain efficacy in shoulder pain 5
• The third-line approach is short-acting oral NSAIDs, which should be used at the lowest effective dose and preferably on-demand rather than continuous use, for the shortest duration necessary to control symptoms 5, 4

Contraindications and Precautions

• Failing to consider patient-specific risk factors (age, comorbidities, concomitant medications) when prescribing naproxen is a precaution to be avoided 1
• Not providing gastroprotection for high-risk patients when taking naproxen is a precaution to be avoided 1
• Using NSAIDs with increasing COX-2 selectivity in patients with cardiovascular disease when other options would suffice is a precaution to be avoided 2
• Non-selective NSAIDs with a gastroprotective agent (PPI) or selective COX-2 inhibitors can be used for patients with increased GI risk, while for patients with increased CV risk, non-selective NSAIDs should be used with caution and coxibs should be avoided completely 5

Comparison of Short-Acting and Long-Acting NSAIDs

5, 4

Monitoring and Follow-up

• Periodically re-evaluate the need for continued NSAID therapy and monitor for adverse effects, especially in high-risk patients 5, 4
• Consider combination therapy with non-pharmacological approaches (splints, exercise) to reduce NSAID requirements, as recommended by the European League Against Rheumatism (EULAR) guidelines 5, 4
• Regular monitoring of blood pressure, renal function, GI symptoms, and CV symptoms is essential during NSAID use to promptly identify and manage potential adverse effects 5
• The American College of Rheumatology recommends using NSAIDs only when patients respond inadequately to paracetamol, and selecting the NSAID based on individual risk profile, with consideration of CV and GI risk factors 5