Can a patient take Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and prednisone together?

NSAIDs and Prednisone Combination: Risks and Management

Patients taking prednisone and NSAIDs together should use a proton pump inhibitor or misoprostol for gastroprotection due to significantly increased risk of gastrointestinal complications. 1, 2, 3

Risks of Combined Therapy

• The combination of prednisone and NSAIDs significantly increases the risk of gastrointestinal complications, including ulceration, bleeding, and perforation 2, 3
• Concomitant use of aspirin (or other NSAIDs) and corticosteroids increases the risk of gastrointestinal side effects 3
• The risk of GI bleeding increases 2-4 fold with a history of peptic ulcer disease and is further elevated with combined therapy 2, 4
• Even short-term use of combined therapy can lead to serious complications 2
• Risk factors for GI complications include:
  • Age over 60 years 2, 5, 4
  • Previous history of peptic ulcer disease 5, 4
  • High NSAID dosage 5
  • Concomitant corticosteroid use 5, 4
  • Use of more than one NSAID simultaneously 5

Recommended Management Approach

Gastroprotection

• Patients treated with glucocorticoids and concomitant NSAIDs should be given appropriate gastroprotective medication, such as proton pump inhibitors (PPIs) or misoprostol 1
• Alternatively, patients could switch to a cyclo-oxygenase-2 selective inhibitor (coxib) 1
• If a patient has two or more risk factors, prophylaxis with misoprostol is indicated 5

Specific Recommendations Based on Risk Factors

1. For patients on prednisone >7.5 mg daily for >3 months:

   • Calcium and vitamin D supplementation should be prescribed 1
   • Consider antiresorptive therapy with bisphosphonates based on risk factors 1

2. For patients with previous gastrointestinal events:

   • Use NSAID + PPI or COX-2 inhibitor + PPI 1

3. For patients without previous GI events but on steroids:

   • Use NSAID + PPI or COX-2 inhibitor 1

Monitoring and Precautions

• Use the lowest effective dose of both medications for the shortest duration possible 2
• Monitor for signs of gastrointestinal bleeding, especially in high-risk patients 2
• Monitor renal function, particularly in older adults or those with existing renal impairment 2
• Watch for fluid retention, elevated blood pressure, or worsening of heart failure 2
• All patients on glucocorticoid therapy for longer than 1 month who will undergo surgery need perioperative management with adequate glucocorticoid replacement 1

Special Considerations

• COX-2 selective inhibitors (like nimesulide) may be safer options when combined with steroids, as they have shown less ulcerogenic potential in animal studies 6
• In some cases, such as acute gout, prednisone can be used as an alternative to NSAIDs when NSAIDs are contraindicated 7
• For combination therapy in acute gout, acceptable approaches include colchicine with NSAIDs or oral corticosteroids with colchicine 1

Common Pitfalls to Avoid

• Failing to provide gastroprotection in high-risk patients 1, 2
• Using NSAIDs alone in patients over 65 years with previous GI events 1
• Continuing the combination longer than absolutely necessary 2
• Overlooking the increased risk during the first 3 months of NSAID therapy, when the risk is highest 4
• Treating NSAID-induced dyspepsia with prophylactic antiulcer therapy without clinical evidence supporting this approach 5