At what age should Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) be avoided?

From the Guidelines

NSAIDs should be avoided in patients aged 65 years and above due to the increased risk of adverse effects, including cardiovascular, cerebrovascular, and gastrointestinal outcomes. When considering the use of NSAIDs in patients, it is essential to take into account the patient's age, as it is a major risk factor for adverse outcomes 1. The use of oral NSAIDs should be personalized according to a patient's gastrointestinal and cardiovascular risk profile, and they should only be used intermittently for the shortest period of time and at the lowest possible dose to control pain 1. Some key points to consider when using NSAIDs in patients include:

• The ESCEO guidelines recommend the use of topical NSAIDs over oral NSAIDs in patients with OA aged ≥75 years and in those at increased risk 1.
• The OARSI guidelines recommend against the use of any oral NSAIDs in patients with an increased risk of cardiovascular events 1.
• Aging kidneys are less efficient at clearing medications, leading to higher blood levels and greater risk of toxicity.
• Elderly patients often take multiple medications that can interact with NSAIDs and have comorbidities that increase risk. For pain management in elderly patients, acetaminophen (Tylenol) is often a safer first-line alternative, though it has its own limitations regarding liver function 1. Any NSAID use in elderly patients should involve careful monitoring for side effects and regular reassessment of the need for continued therapy.

From the FDA Drug Label

As with any NSAIDs, caution should be exercised in treating the elderly (65 years and older). The age at which NSAIDs should be avoided is not explicitly stated, but caution is advised when treating the elderly (65 years and older) 2.

• Key consideration: Caution in the elderly due to potential increased risk of adverse effects.
• Age threshold: 65 years and older.

From the Research

Age Considerations for NSAID Use

• The provided studies do not specify a particular age at which Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) should be avoided, but they do emphasize the need for caution when prescribing NSAIDs to older adults 3, 4, 5, 6.
• Older patients are at a higher risk of adverse effects from NSAIDs, including cardiovascular, renal, and gastrointestinal complications 4, 7, 5.
• The risk of these adverse effects increases with age, and older patients are more likely to have pre-existing conditions that may be exacerbated by NSAID use 4, 5.

Safe Prescribing Practices

• Guidelines recommend using NSAIDs rarely and only in carefully selected patients, particularly in older adults 4.
• The choice of NSAID should be individualized based on the patient's risk factors, such as cardiovascular and gastrointestinal risk 3, 7, 6.
• Topical NSAIDs may be a safer option for patients with localized pain in superficial joints 4.
• Patients with high cardiovascular risk may benefit from naproxen or celecoxib, while those with moderate to high risk of peptic ulcer disease may require co-therapy with a proton pump inhibitor (PPI) 3, 7.

Patient-Specific Factors

• Patients with frequent NSAID use needs, such as elderly patients and those with cardiovascular disease or impaired renal function, may benefit from NSAIDs with lower renal excretion and phase 2 metabolism 6.
• Polymedicated patients, elderly patients, and those with chronic alcohol abuse may be at lower risk for adverse effects with NSAIDs that undergo phase 2 liver biotransformation 6.
• Young patients, patients dealing with acute pain, or those with active and/or chronic symptomatic gastritis may be better suited for selective COX-2 inhibitors 6.