Who should use ibuprofen (nonsteroidal anti-inflammatory drug, NSAID) cautiously?

From the Guidelines

Individuals with certain health conditions, such as a history of stomach ulcers, gastrointestinal bleeding, heart disease, high blood pressure, kidney problems, liver disease, or asthma, should use ibuprofen cautiously. People with these conditions face higher risks of side effects, and their use of ibuprofen should be carefully monitored.

Key Considerations

• Elderly individuals (over 65) are at higher risk of side effects due to age-related changes and comorbidities 1.
• Those taking blood thinners (like warfarin), other NSAIDs, ACE inhibitors, diuretics, or lithium should exercise caution due to potential drug interactions 1.
• Pregnant women, especially in their third trimester, should avoid ibuprofen as it may cause complications for the developing fetus 1.
• When using ibuprofen, take the lowest effective dose for the shortest duration possible, typically 200-400mg every 4-6 hours, not exceeding 1200mg daily without medical supervision 1.
• Take ibuprofen with food to reduce stomach irritation, as it works by blocking enzymes that produce inflammatory compounds called prostaglandins, which can also affect protective prostaglandins in the stomach lining and kidneys 1.

Special Populations

• Patients with a history of peptic ulcer disease or gastrointestinal bleeding should be prescribed gastroprotective therapy, such as proton pump inhibitors, to prevent upper gastrointestinal tract bleeding and perforation 1.
• Patients with compromised fluid status, renal insufficiency, or concomitant use of corticosteroids, anticoagulants, or other NSAIDs should be cautious when using ibuprofen due to increased risk of gastrointestinal complications 1.
• Patients with cardiovascular disease or those at risk of cardiovascular events should be aware of the potential increased risk of myocardial infarction and ischemia associated with NSAID use, including ibuprofen 1.

From the FDA Drug Label

NSAIDs, including ibuprofen tablets should be used with caution in patients with hypertension. Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs NSAIDs should be prescribed with extreme caution in those with a prior history of ulcer disease or gastrointestinal bleeding. Patients with a prior history of peptic ulcer disease and/or gastrointestinal bleeding who use NSAIDs have a greater than 10-fold increased risk for developing a GI bleed compared to patients treated with neither of these risk factors Other factors that increase the risk of GI bleeding in patients treated with NSAIDs include concomitant use of oral corticosteroids or anticoagulants, longer duration of NSAID therapy, smoking, use of alcohol, older age, and poor general health status Most spontaneous reports of fatal GI events are in elderly or debilitated patients and therefore, special care should be taken in treating this population. Patients at greatest risk of renal toxicity are those with impaired renal function, heart failure, liver dysfunction, those taking diuretics and ACE inhibitors, and the elderly As with any NSAIDs, caution should be exercised in treating the elderly (65 years and older).

Ibuprofen should be used cautiously in the following patients:

• Those with hypertension
• Those taking thiazides or loop diuretics
• Those with a prior history of ulcer disease or gastrointestinal bleeding
• Those with impaired renal function, heart failure, liver dysfunction, or those taking diuretics and ACE inhibitors
• Elderly patients (65 years and older)
• Those with concomitant use of oral corticosteroids or anticoagulants
• Those with smoking, use of alcohol, older age, and poor general health status 2

From the Research

Individuals Who Should Use Ibuprofen Cautiously

The following individuals should use ibuprofen cautiously:

• Elderly patients, especially those with a history of peptic ulcer disease, Helicobacter pylori, or those taking anticoagulation or antiplatelet therapy 3, 4, 5
• Patients with chronic conditions requiring long-term treatment with high doses of ibuprofen, as they are at a higher risk of gastrointestinal adverse events 6
• Patients taking aspirin for cardiovascular conditions, as ibuprofen may interfere with the anti-platelet effects of aspirin 7
• Patients with gastrointestinal bleeding risk factors, such as advanced age, history of peptic ulcer disease, or coadministration of corticosteroids 3

Special Considerations

• Patients should be aware of the potential risks of gastrointestinal bleeding, cardiovascular side effects, and NSAID-induced nephrotoxicity associated with ibuprofen use 4
• Healthcare providers should carefully select patients requiring antiplatelet, anticoagulation, or chronic NSAID therapy and consider cotherapy with proton pump inhibitors to reduce the risk of gastrointestinal bleeding 3
• Patients and clinicians should follow guidelines for safe use, including using the lowest dose possible for the shortest time needed 5