Is indomethacin (Nonsteroidal Anti-Inflammatory Drug (NSAID)) safe for a patient with a history of nephrectomy (surgical removal of a kidney)?

From the Guidelines

Indomethacin should be avoided in patients with a history of nephrectomy due to the increased risk of kidney injury and renal failure, as evidenced by the potential for NSAIDs to cause volume-dependent renal failure and interstitial nephritis 1. When considering pain management options for these patients, it is crucial to prioritize alternatives with less kidney risk.

• Alternative pain management options, such as acetaminophen, are recommended for patients with a single kidney, as they pose a lower risk to renal function.
• If an NSAID is necessary, choosing one with a better renal safety profile, such as naproxen or ibuprofen, at conservative doses might be preferable.
• Regular monitoring of kidney function through blood tests (creatinine, BUN) is essential if any NSAID therapy is initiated in these patients. The use of indomethacin, a potent NSAID, can lead to reduced renal blood flow and glomerular filtration rate due to its inhibition of prostaglandin synthesis, which is particularly concerning in patients with reduced renal reserve, such as those with a history of nephrectomy 1.
• Patients with a single kidney are at higher risk for NSAID-induced kidney injury, making it essential to exercise caution when prescribing NSAIDs, including indomethacin.
• The potential for NSAID-related renal complications can be increased by certain medications, such as beta blockers and angiotensin-converting enzyme (ACE) inhibitors, which should be considered when managing patients with a history of nephrectomy 1.

From the FDA Drug Label

Renal Effects Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. Renal toxicity has also been seen in patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion In these patients, administration of a non-steroidal anti-inflammatory drug may cause a dose dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate over renal decompensation Patients at greatest risk of this reaction are those with impaired renal function, heart failure, liver dysfunction, those taking diuretics and ACE inhibitors, patients with volume depletion, and the elderly. Advanced Renal Disease No information is available from controlled clinical studies regarding the use of indomethacin in patients with advanced renal disease. Therefore, treatment with indomethacin is not recommended in these patients with advanced renal disease. If indomethacin therapy must be initiated, close monitoring of the patient's renal function is advisable

The use of indomethacin in a patient with a history of nephrectomy may pose a risk due to the potential for renal toxicity and reduced renal blood flow. Patients with a history of nephrectomy may have impaired renal function, which increases the risk of renal decompensation. Although the label does not directly address the safety of indomethacin in patients with a history of nephrectomy, it does recommend close monitoring of renal function if therapy is initiated in patients with advanced renal disease. Given the potential risks, it is recommended to exercise caution when considering the use of indomethacin in a patient with a history of nephrectomy 2.

From the Research

Safety of Indomethacin for Patients with a History of Nephrectomy

• The use of indomethacin, a Nonsteroidal Anti-Inflammatory Drug (NSAID), in patients with a history of nephrectomy (surgical removal of a kidney) has been studied in various research papers 3, 4, 5, 6, 7.
• A study published in 1994 found that indomethacin had identical effects on renal function in healthy uninephrectomized subjects and in healthy control subjects, suggesting that the drug may be safe for patients with a history of nephrectomy 3.
• Another study published in 2020 found that medical nephrectomy with ACE inhibitors and/or non-steroidal anti-inflammatory drugs, including indomethacin, was a safe and non-invasive therapy to minimize proteinuria in children with end-stage renal disease (ESRD) due to nephrotic syndrome before kidney transplantation 4.
• However, a study published in 1989 found that indomethacin significantly reduced creatinine clearance and renal plasma flow in healthy subjects, suggesting that the drug may have deleterious effects on renal function 5.
• A retrospective cohort study published in 2020 found that the use of NSAIDs, including indomethacin, for patient-controlled analgesia after laparoscopic nephrectomy did not affect postoperative renal function or increase the risk of postoperative acute kidney injury 6.
• A post-hoc analysis published in 2012 found that indomethacin reduced glomerular and tubular damage markers but not renal inflammation in chronic kidney disease patients, suggesting that the drug may have beneficial effects on renal function in certain patients 7.

Key Findings

• Indomethacin may be safe for patients with a history of nephrectomy, but its use should be carefully monitored due to potential deleterious effects on renal function 3, 5.
• The drug may have beneficial effects on renal function in certain patients, such as those with chronic kidney disease or nephrotic syndrome 4, 7.
• Further studies are needed to fully understand the safety and efficacy of indomethacin in patients with a history of nephrectomy 3, 4, 5, 6, 7.