1. Enteric-coated tablets. Enteric-coated ASA are supposed to have less GI symptoms than regular ASA, but there is no evidence that the enteric coating decreases gastritis or peptic ulcers.
2. Liquid formulations. Ibuprofen, naproxen, magnesium salicylate, and indomethacin are available in liquid formulations that are designed for patients who have difficulty swallowing pills and for children.
3. Slow release. This formulation is designed to give a short-acting drug a longer half-life so that it can be taken only once or twice a day. Costs are for generics with a drug coupon (e.g., Good Rx):
Naprosyn (Naprelan): 375 mg, 500 mg, or 750 mg tabs. Dose: 750 to 1500 mg qd. Cost: generic $331 to $480/month.
4. Topical formulations. Salicylate-containing creams (Bengay, Aspercreme) and diclofenac formulations (liquid drops, gel, and patch) are available in the United States. Topical diclofenac offers the potential for pain relief with decreased incidence of serious side effects in comparison to oral preparations. Studies involving the topical liquid diclofenac have shown low systemic absorption of the drug (6.6%; mean peak plasma concentrations nearly 100-fold less than oral formulation). Clinical benefit has been demonstrated in the hand, hip, and knee osteoarthritis for some of these formulations. Costs are with drug coupon:
Diclofenac 1% topical gel (Voltaren gel): 2 g bid–qid for small joints and 4g bid–qid for large joints. Max dose 32 g/day. Cost $100 to $125/month (16 g daily dose).
Diclofenac 1.3% topical patch (Flector patch): two patches/day. Cost $675/month each area treated (60 patches).
Diclofenac 1.5% topical solution (Pennsaid): 40 drops/knee bid–qid. Cost: $55 to $72/month per knee (40 drops tid).
5. Combination medications. NSAID combined with a gastroprotective agent. Costs are with drug coupon:
Diclofenac sodium with misoprostol (Arthrotec): 50 mg/200 mcg and 75 mg/200 mcg tabs. Max dose 150 to 200 mg diclofenac. Cost: 50 mg/200 mcg bid is $70/month.
Naproxen plus esomeprazole (Vimovo): 375 mg/20 mg or 500 mg/20 mg bid. Cost: $2500/month.
Ibuprofen plus famotidine (Duexis): 800 mg/26.6 mg tid. Cost: $2500/month.