Which patients should not take Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)?

Patients Who Should Not Take NSAIDs

NSAIDs should be completely avoided in patients with a history of recent ulcer complications, concomitant anticoagulant use, allergic reactions to NSAIDs, immediately before or after heart bypass surgery, and in pregnant women after 30 weeks of gestation. 1, 2, 3

High-Risk Patients Who Should Avoid NSAIDs

• History of GI complications: Patients with prior ulcer bleeding or complications should avoid NSAIDs completely, as they have the highest risk of recurrent bleeding 3
• Anticoagulant therapy: Patients receiving anticoagulants should avoid NSAIDs due to potentially disastrous consequences of GI bleeding 3
• Allergic reactions: Patients who have had asthma attacks, hives, or other allergic reactions with aspirin or other NSAIDs 1, 2
• Cardiovascular risk: Patients immediately before or after coronary artery bypass graft (CABG) surgery or those who recently had a heart attack 1, 2
• Late pregnancy: Women after approximately 30 weeks of pregnancy should not take NSAIDs 1

Renal Risk Factors

• Pre-existing renal disease: NSAIDs should be avoided in patients with pre-existing kidney disease to prevent acute renal failure 3, 4
• Congestive heart failure: Patients with heart failure should avoid NSAIDs due to risk of worsening renal function 3, 4
• Cirrhosis: Patients with liver cirrhosis should avoid NSAIDs due to risk of renal failure 3, 4
• Compromised fluid status: Patients with hypovolemia or dehydration are at increased risk for NSAID-induced kidney injury 4
• Advanced age: Patients over 60 years have increased risk of renal complications with NSAIDs 4

Gastrointestinal Risk Factors

• Multiple risk factors: Patients with multiple GI risk factors (older age, high-dose NSAIDs, history of ulcer, concomitant use of corticosteroids, anticoagulants, or SSRIs) 3
• Very high-risk patients: Those with recent ulcer complications should avoid NSAIDs altogether 3
• Concomitant medications: Patients taking corticosteroids, anticoagulants, antiplatelet drugs, or SSRIs have increased risk of GI bleeding 2, 5

Cardiovascular Risk Factors

• Treatment-resistant hypertension: NSAIDs can worsen hypertension (average increase of 5 mm Hg) 6, 7
• High cardiovascular risk: Patients with high risk of cardiovascular disease should avoid NSAIDs when possible 6, 7
• Recent myocardial infarction: NSAIDs should be avoided in patients who recently had a heart attack 1

Special Considerations

• Pregnancy: NSAIDs should not be used after about 30 weeks of pregnancy and should be used with caution between 20-30 weeks 1
• Multiple NSAIDs: Taking more than one NSAID simultaneously significantly increases risk of adverse effects 4
• Drug interactions: NSAIDs can interact with antihypertensives, particularly ACE inhibitors and angiotensin receptor blockers, reducing their effectiveness and increasing renal risk 3, 4

Risk Mitigation When NSAIDs Cannot Be Avoided

If NSAIDs must be used in higher-risk patients (but not those who should absolutely avoid them):

• GI protection: Use proton pump inhibitors (PPIs), double-dose histamine H2 blockers, or misoprostol with NSAIDs in patients with moderate GI risk 3, 7
• Cardiovascular considerations: If NSAID treatment cannot be avoided in patients with high cardiovascular risk, naproxen or celecoxib are preferred 7
• Monitoring: Consider monitoring serum creatinine levels after initiation of NSAID therapy in at-risk patients, particularly those taking ACE inhibitors and angiotensin receptor blockers 3, 4
• Dose and duration: Always use the lowest effective dose for the shortest possible time 8

NSAIDs remain valuable medications when used appropriately, but careful patient selection and risk assessment are essential to minimize potentially serious adverse events.