What are the contraindications for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

Contraindications for NSAIDs

NSAIDs are contraindicated in patients with coronary artery bypass graft (CABG) surgery, history of NSAID-induced asthma or allergic reactions, severe heart failure, advanced kidney disease, cirrhosis, and during the third trimester of pregnancy. 1, 2

Absolute Contraindications

• Perioperative pain in coronary artery bypass graft (CABG) surgery 1, 2
• Known hypersensitivity to NSAIDs (including aspirin-induced asthma, urticaria, or allergic-type reactions) 1
• Active gastrointestinal bleeding 3
• Severe heart failure 3
• Severe chronic kidney disease 4
• Cirrhotic liver disease 3
• Third trimester of pregnancy (risk of premature closure of ductus arteriosus) 3

Relative Contraindications (High-Risk Conditions)

Cardiovascular Risk

• History of cardiovascular disease or high cardiovascular risk 3
• Treatment-resistant hypertension 4
• Heart failure (NSAIDs can worsen heart failure) 3
• Concurrent use with low-dose aspirin (may reduce cardioprotective effects) 3

Gastrointestinal Risk

• History of peptic ulcer disease or GI bleeding 3, 5
• Age ≥60 years (risk increases with age, especially ≥75 years) 5
• Concomitant use of corticosteroids or anticoagulants 1
• Significant alcohol use 5
• H. pylori infection 5

Renal Risk

• Pre-existing renal insufficiency 3
• Concomitant use of ACE inhibitors or ARBs 3
• Volume depletion or dehydration 3
• Advanced age 3

Hematologic Risk

• Anticoagulant therapy (increased bleeding risk) 3
• Platelet dysfunction 3
• Planned surgical procedures (increased perioperative bleeding) 3

Risk Stratification and Recommendations

For Patients with Cardiovascular Risk:

1. Avoid NSAIDs if possible in patients with established cardiovascular disease 3
2. If NSAID is necessary:
   • Naproxen is preferred (lowest cardiovascular risk) 3
   • Use lowest effective dose for shortest duration 3
   • Monitor blood pressure and renal function 4

For Patients with Gastrointestinal Risk:

1. Low risk: Standard NSAID may be used
2. Moderate risk: Either:
   • Non-selective NSAID + PPI
   • COX-2 selective inhibitor 5
3. High risk (prior ulcer bleeding):
   • COX-2 selective inhibitor + PPI 5
   • Consider avoiding NSAIDs altogether 3

For Patients with Renal Risk:

1. Screen for unrecognized CKD before starting NSAIDs in high-risk patients 4
2. Avoid NSAIDs in severe CKD 4
3. Monitor serum creatinine after initiation in at-risk patients 3
4. Consider dose reduction in mild-moderate renal impairment 3

Special Populations

Elderly Patients

• Higher risk for adverse effects across all organ systems 3
• Use lowest effective dose for shortest duration 6
• Consider NSAIDs with lower renal excretion (acemetacin, diclofenac, etodolac) 6

Pregnant Women

• Contraindicated in third trimester 3
• May be used with caution in first and second trimesters 3

Breastfeeding Women

• Ibuprofen, indomethacin, and naproxen are considered safe 3

Monitoring Recommendations

For patients on NSAIDs, especially long-term:

• Regular blood pressure monitoring 5
• Periodic laboratory assessment (renal function, electrolytes, CBC) 5
• Monitoring for GI symptoms 5
• Fecal occult blood testing 5

Common Pitfalls to Avoid

1. Failing to assess cardiovascular risk before prescribing NSAIDs
2. Overlooking drug interactions, particularly with aspirin, anticoagulants, and antihypertensives
3. Not providing gastroprotection in high-risk patients
4. Continuing NSAIDs despite signs of adverse effects
5. Using NSAIDs in perioperative CABG setting (absolute contraindication)
6. Prescribing NSAIDs to patients with cirrhosis (increases risk of bleeding and renal failure) 3

By carefully considering these contraindications and using appropriate risk stratification, clinicians can minimize the potential for serious adverse events associated with NSAID use.