Nimesulide and Acute Kidney Injury with Thrombocytopenia
Nimesulide can cause acute kidney injury, but there is no established causal relationship between nimesulide and thrombocytopenia based on available evidence.
Renal Toxicity of Nimesulide
Nimesulide, like other NSAIDs, carries well-documented nephrotoxic potential:
NSAIDs should be avoided in patients with renal disease due to the risk of worsening kidney function 1, 2. This recommendation applies broadly to all NSAIDs, including nimesulide.
Nimesulide has been associated with renal adverse reactions in spontaneous reporting data, with 11 out of 120 reports involving suspected renal impairment 3. Six of these cases required hospitalization, and most patients had taken the drug for only a short period 3.
The mechanism involves prostaglandin-dependent renal effects common to NSAIDs 4. Nimesulide causes acute but transient decreases in renal hemodynamics, reduces urinary prostaglandin E2 excretion, and can cause sodium and potassium retention 4.
In furosemide-treated subjects (a model of volume depletion where renal function depends on prostaglandins), nimesulide induced transient renal hemodynamic changes and blunted diuretic effects 4.
Thrombocytopenia Evidence
The available evidence does not support nimesulide causing thrombocytopenia:
A controlled study of nimesulide 200 mg daily for 7 days in healthy volunteers showed no significant changes in platelet count, bleeding time, or any hemostasis parameters 5. All bleeding times remained within normal range throughout the study 5.
Higher doses (up to 800 mg daily) showed no clinically significant hematological alterations in screening tests 6.
While thrombocytopenia is common in critically ill patients with severe acute kidney injury 7, this appears related to the underlying critical illness and AKI itself rather than specific medications like nimesulide.
Clinical Implications
If a patient develops both AKI and thrombocytopenia while taking nimesulide:
Discontinue nimesulide immediately 3, as the AKI is likely drug-related given the known nephrotoxic profile of NSAIDs.
Investigate alternative causes for thrombocytopenia, as this is not an established adverse effect of nimesulide. Consider other medications, underlying conditions, sepsis, or critical illness as potential etiologies 7.
Monitor renal function closely, as most reported cases of nimesulide-associated renal impairment resolved after drug discontinuation 3.
Risk Factors and Precautions
Patients at highest risk for nimesulide-induced AKI include those with:
- Pre-existing renal impairment 1, 2
- Volume depletion or concurrent diuretic use 4
- Heart failure 8
- Concurrent use of ACE inhibitors or ARBs, which increases hyperkalemia risk 8
Avoid NSAIDs entirely in patients with GFR < 30 mL/min/1.73 m² and use cautiously with prolonged therapy when GFR < 60 mL/min/1.73 m² 1.