From the Guidelines
For patients with impaired renal function (low GFR), all NSAIDs should be avoided if possible, and acetaminophen or alternative pain management strategies should be considered first. According to the most recent guideline evidence 1, NSAIDs or COX-2 inhibitors should generally be avoided in patients with or at risk for chronic kidney disease (CKD) and in those patients at risk for serious upper gastrointestinal (UGI) toxicity. The guideline also recommends that assessment of renal function should occur, and NSAIDs and COX-2 inhibitors should be avoided in patients with estimated glomerular filtration rate (eGFR) <30 ml/min per 1.73 m2.
If an NSAID must be used, the choice of NSAID should be based on the individual patient's risk factors and medical history. However, there is no strong evidence to support the use of one NSAID over another in patients with low GFR. The 2014 KDOQI commentary 1 also recommends avoiding NSAIDs in people with GFR < 30 ml/min/1.73 m2 and notes that prolonged therapy is not recommended in people with GFR < 60 ml/min/1.73 m2.
Some key points to consider when managing pain in patients with low GFR include:
- Avoiding NSAIDs and COX-2 inhibitors in patients with eGFR <30 ml/min per 1.73 m2
- Considering alternative pain management strategies, such as acetaminophen (up to 3000 mg daily in divided doses), topical NSAIDs, or non-pharmacological approaches
- Assessing baseline renal function and monitoring renal function within 1-2 weeks of initiating any NSAID therapy
- Consulting with a nephrologist if pain control remains inadequate and NSAID therapy is being considered
- Educating patients about potential warning signs of worsening renal function, including decreased urine output, edema, and unexplained weight gain.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
NSAID Options for Low GFR Patients
- Patients with impaired renal function (low Glomerular Filtration Rate (GFR)) should be cautious when using Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) as they can induce renal function abnormalities 2.
- Sulindac is considered a potentially renal-sparing NSAID and may be the preferred option for patients with impaired renal function 3.
- A study found that sulindac produced a small, but significant, reduction in creatinine clearance in patients with moderate chronic renal insufficiency, but this effect was reversible 4.
- Another study found that sulindac did not significantly alter the excretion of prostaglandins and produced only a minor reversible change in renal function in patients with chronic renal disease 4.
- In patients with renal insufficiency, long-acting NSAIDs such as piroxicam and sulindac may cause significant chronic decrements in GFR, but short-acting ibuprofen may not have this effect 5.
Key Considerations
- NSAID prescribing should be decreased in patients with low GFR, and estimated GFR reporting may result in safer prescribing 6.
- Patients who stop taking NSAIDs may experience significant improvements in estimated renal function 6.
- The choice of NSAID and dosage should be carefully considered in patients with impaired renal function, and renal function should be monitored while being treated with long-acting NSAIDs 5.