NSAIDs in Teenagers: Evidence-Based Guidelines
NSAIDs are safe and effective for teenagers when used appropriately, with baseline laboratory testing recommended before initiation and monitoring every 6-12 months during chronic use, particularly for complete blood count, liver function, and renal function. 1
Approved Indications and General Use
NSAIDs are conditionally recommended as adjunct therapy for teenagers with juvenile idiopathic arthritis and polyarthritis, though the supporting evidence quality is very low. 1 For teenagers with active enthesitis (inflammation at tendon-bone insertion sites), NSAIDs are strongly recommended over no treatment, despite very low quality evidence, based on established analgesic effects and data from adult disease. 1
Critical Monitoring Requirements
Baseline Testing
Baseline laboratory evaluation is conditionally recommended prior to treatment initiation for all NSAIDs. 1 This should include:
- Complete blood count with differential 1
- Liver function tests (ALT and AST) 1
- Renal function tests (BUN, creatinine, urinalysis) 1
Ongoing Monitoring
Monitoring via CBC, liver function tests, and renal function tests every 6-12 months is conditionally recommended for teenagers on chronic NSAID therapy. 1 While gastrointestinal bleeding, liver toxicity, and kidney toxicity may be rare in children compared to adults, periodic laboratory monitoring remains important for those receiving long-term NSAIDs. 1
Clinicians should actively inquire about gastrointestinal symptoms (nausea, abdominal pain, heartburn), as teenagers may not spontaneously report these common side effects. 1
Absolute Contraindications and High-Risk Situations
Do Not Use NSAIDs When:
- Dehydration is present - teenagers with diarrhea and vomiting (with or without fever) should not receive NSAIDs due to risk of renal damage 2, 3
- Known hypersensitivity to the specific NSAID or other NSAIDs exists 4, 2
- Active wheezing or persistent asthma is present 2
- During varicella infection 2
- Immediately before or after coronary artery bypass graft surgery 4
- Pregnancy at approximately 20 weeks or later - NSAIDs may harm the unborn baby and should not be used after 30 weeks of pregnancy 4
High-Risk Populations Requiring Caution:
- Teenagers with chronic illness 3
- Those using alcohol 3
- Concurrent use of corticosteroids, anticoagulants, SSRIs, or SNRIs (increased bleeding risk) 4
- Pre-existing liver or kidney problems 4
- History of gastrointestinal ulcers or bleeding 4
Cardiovascular Considerations
The FDA requires a black box warning for NSAIDs regarding increased risk of heart attack and stroke that can lead to death. 4 This risk may occur early in treatment and increases with higher doses and longer duration of use. 4 NSAIDs should be avoided after a recent heart attack unless specifically directed by a healthcare provider. 4
Appropriate Use Principles
NSAIDs should only be used exactly as prescribed, at the lowest effective dose, for the shortest time needed. 4 For over-the-counter use, if NSAIDs are needed for longer than 10 days, a physician should be consulted. 1
Role in Treatment Algorithms:
- For inflammatory arthritis: NSAIDs serve as adjunct therapy alongside disease-modifying antirheumatic drugs (DMARDs), not as monotherapy 1
- For enthesitis: NSAIDs are first-line, with TNF inhibitors conditionally recommended if symptoms persist despite NSAID therapy 1
- For sacroiliitis: NSAIDs are initial therapy, with bridging oral glucocorticoids (<3 months) conditionally recommended for persistent symptoms 1
Common Pitfalls to Avoid
Do not use NSAIDs as routine antipyretics - ibuprofen should not be used for fever except in rare cases, as it is primarily indicated for inflammatory pain in children. 2 The evidence from 2000 onward demonstrates that while gastrointestinal events are rare, they can involve both upper and lower digestive tract lesions when they occur. 2
Do not dismiss the need for monitoring - even though serious adverse events are uncommon in teenagers compared to adults, renal impairment and gastrointestinal complications can occur, particularly in the setting of dehydration or concurrent illness. 5, 3
Do not combine with other nephrotoxic medications without careful monitoring - risk factors for NSAID nephrotoxicity include use of other medications that affect renal function. 3
Specific Adverse Events to Monitor
Teenagers and caregivers should be instructed to stop NSAIDs and seek immediate medical attention for: 4
- Shortness of breath or chest pain
- Weakness on one side of body or slurred speech
- Vomiting blood or black, tarry stools
- Yellowing of skin or eyes
- Unusual weight gain or swelling of extremities
- Skin rash or blisters with fever