II. Epidemiology
- NSAIDs are top cause of Kidney injury and Renal Insufficiency in the elderly
III. Physiology
- NSAIDs decrease synthesis of renal Prostaglandins
- Prostaglandins vasodilate renal vessels
- NSAIDs therefore reduce renal Blood Flow
IV. Risk Factors: NSAID related Acute Renal Failure
- Elderly
- Hypovolemia or Dehydration
- Heat Related Illness
- Acute illness (e.g. Viral Infection)
- Ineffective circulation
- Concurrent medications
V. Adverse Effects: General Renal effects
-
NSAID Related Fluid and Electrolyte abnormalities
- Edema (may provoke CHF)
- Hyperkalemia
- Acute Renal Failure
- Acute papillary Necrosis
VI. Management: Practice Guidelines for NSAID use in the elderly
- Establish a definitive treatment diagnosis
- Inflammatory condition (e.g. Rheumatoid Arthritis)
- NSAID indicated
- COX2 Inhibitor offers no advantage regarding nephrotoxicity
- Non-Inflammatory condition
- Inflammatory condition (e.g. Rheumatoid Arthritis)
- Use the lowest effective dose of NSAIDs for the shortest possible duration
- Occasional OTC NSAID (Naproxen or Ibuprofen) may be tolerated
- Consider Topical NSAID for localized pain (e.g. Hand Osteoarthritis)
- Maintain hydration and monitor for adverse effects (e.g. edema)
- Monitoring
- Perform baseline Renal Function and repeat at 2 weeks, then every 3-12 months
- See NSAIDs for lab monitoring
- Creatinine and Serum Potassium
- Consider screening for Proteinuria
- Choose NSAID with high benefit to risk ratio (e.g. Sulindac)
- Understand that no NSAID is considered safest, and all carry a risk for Renal Injury
- Good efficacy
- Lower renal toxicity
- Avoid the most NSAIDS most commonly associated with nephrotoxicity
- Consider Gastric protection or COX2 Inhibitor
- Continue to monitor efficacy and side effects
- Do no harm
- Avoid combining high risk medications
- Never use two different types of systemic NSAIDs together
- Avoid NSAIDs in reduced renal perfusion
- Avoid NSAIDs with ACE Inhibitors or Angiotensin Receptor Blockers
- Avoid NSAIDs with Diuretics
- Avoid NSAIDs in Dehydration
- Avoid combinations predisposing to Hyperkalemia
- Avoid NSAID with Potassium sparing Diuretic
- Avoid NSAID with ACE Inhibitor
- Avoid NSAID with Trimethoprim-Sulfamethoxazole (especially with ACE Inhibitors)
VII. References
- (2022) Presc Lett 29(10): 56