From the Guidelines
Contraindications to NSAIDs include active peptic ulcer disease, history of NSAID-induced ulcers or gastrointestinal bleeding, severe heart failure, advanced chronic kidney disease, third trimester of pregnancy, history of hypersensitivity reactions to NSAIDs, and significant liver disease. When considering the use of NSAIDs, it is crucial to weigh the potential benefits against the risks, particularly in patients with certain medical conditions.
Conditions Requiring Caution
- Hypertension: NSAIDs can worsen hypertension due to their effect on renal blood flow and fluid balance 1.
- Mild to moderate heart failure: The use of NSAIDs in these patients requires careful monitoring due to the potential for worsening heart failure 1.
- Asthma, particularly aspirin-exacerbated respiratory disease: Patients with asthma should use NSAIDs with caution, as they can trigger or worsen respiratory symptoms 1.
- Inflammatory bowel disease: The use of NSAIDs in patients with inflammatory bowel disease can exacerbate symptoms and should be approached with caution.
- Concomitant use of anticoagulants like warfarin: This combination increases the risk of gastrointestinal bleeding and requires careful monitoring 1.
Alternative Considerations
NSAIDs should be avoided in patients taking other nephrotoxic medications and those with dehydration or volume depletion. Alternative pain medications like acetaminophen, topical analgesics, or in some cases, selective COX-2 inhibitors (with appropriate precautions) may be considered when traditional NSAIDs are contraindicated. The most recent and highest quality study 1 emphasizes the importance of cautious use of NSAIDs, especially in older adults and those with compromised renal function or history of gastrointestinal bleeding.
From the Research
Contraindications to NSAIDs
The following are contraindications to NSAIDs:
- History of peptic ulcer disease or gastrointestinal bleeding 2, 3, 4, 5, 6
- Older age, as the risk of gastrointestinal complications increases with age 3, 4, 6
- Presence of Helicobacter pylori infection, as it increases the risk of gastrointestinal complications 3, 6
- Use of anticoagulants or corticosteroids, as it increases the risk of gastrointestinal bleeding 4, 6
- High-dose or multiple NSAIDs, including NSAID plus low-dose aspirin 4
- Inflammatory bowel disease, as NSAIDs can increase the risk of clinical relapse 5
- Active inflammation, as NSAIDs should be avoided as long-term treatment or with high doses 5
Special Considerations
- Patients with a history of rheumatoid arthritis or osteoarthritis may still be prescribed NSAIDs, but caution is advised 2
- Patients at high risk of colorectal cancer may be prescribed aspirin or COX-2 inhibitors as chemopreventive drugs, but cardiovascular and GI risk must be assessed before using these agents 3
- Patients with cardiovascular risk factors should be carefully evaluated before initiating NSAID therapy 3, 4