From the Guidelines
NSAIDs should generally be avoided in patients with end-stage chronic disease, especially those with renal or hepatic impairment, due to the potential for worsening kidney function, increasing bleeding risk, and precipitating other complications. For patients with end-stage renal disease, NSAIDs can worsen kidney function by reducing prostaglandin-mediated vasodilation of renal arterioles, potentially accelerating disease progression and causing fluid retention, hypertension, and electrolyte disturbances, as noted in a study published in the American Family Physician 1. In end-stage liver disease, NSAIDs may increase bleeding risk due to impaired platelet function and coagulopathy, while also potentially precipitating hepatorenal syndrome. For end-stage heart failure patients, NSAIDs can cause sodium and fluid retention, worsening heart failure symptoms and potentially triggering acute decompensation.
Some key considerations for NSAID use in patients with end-stage chronic disease include:
- The risk of gastrointestinal bleeding, which can be mitigated with the use of proton pump inhibitors or misoprostol, as suggested in a study published in the Mayo Clinic Proceedings 1
- The potential for worsening renal function, which can be assessed through regular monitoring of estimated glomerular filtration rate (eGFR) and avoidance of NSAIDs in patients with eGFR <30 ml/min per 1.73 m2, as recommended in the 2020 VA/DoD Clinical Practice Guideline for the Non-Surgical Management of Hip & Knee Osteoarthritis 1
- The increased risk of cardiovascular complications, such as myocardial infarction, which can be minimized by avoiding COX-2 inhibitors in persons at risk of cardiovascular events and using NSAIDs with caution in persons with hypertension, as noted in a study published in the American Family Physician 1
Alternative pain management strategies should be considered, such as:
- Acetaminophen (up to 2-3g daily with dose reduction in liver disease), as recommended in the 2020 VA/DoD Clinical Practice Guideline for the Non-Surgical Management of Hip & Knee Osteoarthritis 1
- Topical analgesics
- Carefully monitored opioids at the lowest effective dose, as suggested in a study published in the Annals of Internal Medicine 1 Any consideration of NSAID use in these patients should involve careful risk-benefit assessment, using the lowest effective dose for the shortest duration possible, with close monitoring of organ function, electrolytes, and clinical status.
From the FDA Drug Label
NSAIDs should only be used: exactly as prescribed at the lowest dose possible for your treatment for the shortest time needed Patients and physicians should remain alert for signs and symptoms of GI ulceration and bleeding during NSAID therapy and promptly initiate additional evaluation and treatment if a serious GI adverse event is suspected. Most spontaneous reports of fatal GI events are in elderly or debilitated patients and therefore, special care should be taken in treating this population. For high risk patients, alternate therapies that do not involve NSAIDs should be considered.
The use of NSAIDs in patients with end-stage chronic disease should be approached with caution. These patients may be at a higher risk for adverse events, such as gastrointestinal bleeding, due to their underlying condition.
- Key considerations for using NSAIDs in these patients include:
- Using the lowest effective dose for the shortest possible duration
- Monitoring for signs and symptoms of GI ulceration and bleeding
- Considering alternate therapies that do not involve NSAIDs It is essential to weigh the potential benefits of NSAID therapy against the risks and to closely monitor patients for any adverse events 2, 3.
From the Research
NSAID Use in End-Stage Chronic Disease
- The use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) in patients with end-stage chronic disease is a complex issue, with both benefits and risks to consider 4, 5, 6, 7, 8.
- According to a study published in the American Family Physician, NSAIDs are effective for managing acute pain, but should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 4.
- Another study published in the Expert Opinion on Pharmacotherapy suggests that limited use of NSAIDs may be justified in end-stage kidney disease (ESKD) patients, despite the potential risks, due to the difficulty in achieving adequate pain control in this population 5.
- The risk of cardiovascular adverse events associated with NSAID use is a concern, particularly in patients with pre-existing cardiovascular disease, and the choice of NSAID and dose should be individualized based on the patient's risk profile 6, 8.
- A study published in the American Journal of Kidney Diseases notes that NSAID use has been associated with acute kidney injury, progressive loss of glomerular filtration rate, and other nephrotoxicity syndromes in patients with chronic kidney disease (CKD), and recommends cautious use of NSAIDs in this population 7.
- The use of COX-2 selective agents, such as celecoxib, may be safer for the gastrointestinal tract, but has a worse cardiovascular profile, while naproxen seems safer for the cardiovascular system but has higher gastrointestinal toxicity 8.
Considerations for NSAID Use
- The decision to use NSAIDs in patients with end-stage chronic disease should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 4, 5, 6, 7, 8.
- Patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease should be closely monitored for potential adverse effects of NSAID use 4, 6, 7, 8.
- The choice of NSAID and dose should be individualized based on the patient's risk profile, and the lowest effective dose should be used for the shortest amount of time necessary 6, 8.
- Alternative analgesic options, such as acetaminophen or opioids, may be considered for patients who are at high risk of adverse effects from NSAID use 4, 5, 7.