Contraindications for NSAID Use
NSAIDs are absolutely contraindicated in patients with active peptic ulcer disease, chronic kidney disease, heart failure, and in the perioperative setting of coronary artery bypass graft surgery due to significant risks of serious complications including gastrointestinal bleeding, renal failure, and cardiovascular events. 1, 2, 3
Absolute Contraindications
- Active peptic ulcer disease - NSAIDs significantly increase the risk of GI bleeding and perforation in patients with existing ulcers 1
- Chronic kidney disease - NSAIDs can cause acute kidney injury and worsen existing renal impairment 1, 4
- Heart failure - NSAIDs promote sodium retention and can precipitate or worsen heart failure 1, 4
- Perioperative pain in coronary artery bypass graft (CABG) surgery - increased risk of cardiovascular thrombotic events 2, 3
- History of NSAID-induced asthma or hypersensitivity reactions 4
Relative Contraindications and High-Risk Conditions
Cardiovascular Risk Factors
- History of cardiovascular disease or stroke 1, 5
- Uncontrolled or treatment-resistant hypertension 4, 6
- Concomitant use of anticoagulants (significantly increases bleeding risk) 4
- Patients taking aspirin for cardioprophylaxis should avoid ibuprofen specifically 1
Gastrointestinal Risk Factors
- History of peptic ulcer disease 1
- Advanced age (risk increases approximately 4% per year of age) 1, 5
- Helicobacter pylori infection (increases risk 2-4 fold) 1
- Concomitant use of corticosteroids or selective serotonin reuptake inhibitors (SSRIs) 1, 4
- History of GI bleeding or ulcer complications (very high risk) 1, 4
Renal Risk Factors
- Liver cirrhosis (increases risk of renal failure) 4
- Hypovolemia or dehydration 4
- Concomitant use of ACE inhibitors or angiotensin receptor blockers 4, 7
- Age over 60 years 5, 4
Other Contraindications
- Multiple NSAID use - patients should not take more than one NSAID simultaneously 1, 4
- Severe hepatic insufficiency 8
Risk Mitigation Strategies When NSAIDs Cannot Be Avoided
For Gastrointestinal Protection
- Patients with moderate GI risk should use a proton pump inhibitor (PPI) or misoprostol for gastroprotection 1, 5
- Patients taking COX-2 selective inhibitors with aspirin should also use a PPI or misoprostol 1
- For very high-risk patients (history of ulcer complications), avoid NSAIDs completely if possible, or use a COX-2 inhibitor plus PPI if absolutely necessary 1, 4
For Cardiovascular Risk
- For patients with high cardiovascular risk who require NSAIDs, naproxen or low-dose celecoxib are preferred options 5, 6
- Monitor blood pressure regularly, especially when initiating therapy 5, 6
For Renal Risk
- Monitor renal function periodically, especially in high-risk patients 1, 9
- Use the lowest effective dose for the shortest duration possible 5, 8
Special Considerations
- Elderly patients are at significantly higher risk for all NSAID-related complications (GI, renal, and cardiovascular) 1, 5
- Patients with liver disease should be monitored for hepatic toxicity with periodic liver function tests 9
- NSAIDs can interact with many medications commonly used in cardiovascular disease, including diuretics, beta-blockers, ACE inhibitors, and digoxin 7
- The risk of NSAID-related complications increases with dose and duration of treatment 1, 5
When prescribing NSAIDs, clinicians should carefully assess the patient's risk profile, select the most appropriate agent, consider gastroprotective strategies when indicated, and monitor for complications throughout the course of therapy 5, 4.