Friday, 03 Apr 2020

You are here

NSAID Safety Guidelines

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for acute or chronic arthritis, headache, visceral pain, postoperative pain, etc but come with a small but significant risk of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications. The journal Gut has published a multidisciplinary effort from multiple societies (including APLAR/, PAGE, APSDE, APSH, APSN, PoA from Australia, Hong Kong, China, Japan, Taiwan) to formulate new recommendations on the safe use of NSAIDs.

A systematic literature review of randomised control trials and observational studies,  resulted in 329 papers that were evaluated using the  Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach for developing evidence-based recommendations.

In summary, these recommendations state:

  • NSAIDs should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD)
  • Blood pressure should be measured before treatment with a NSAID is started
  • Unrecognised CKD should be screened in high risk cases
  • Unexplained iron-deficiency anaemia should be investigated
  • In those with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred
  • For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used
  • For those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed
  •  For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered.
  • Blood pressure and renal function should be monitored in most cases.

NSAIDs can be valuable agents in many clinical scenarios. However, toxicity can be minimized with proper patient selection and selection of specific agent, and the appropriate use of ulcer prophylaxis and monitoring with NSAID therapy.

The author has no conflicts of interest to disclose related to this subject

Add new comment

More Like This

Universal Masking for COVID?

In early March 2020, there were widespread recommendations that wearing routine "surgical masks" by the public sector was not likely to be helpful or advisable. Now we are hearing of a 180 degree shift in thinking with the CDC, leading health officials and the current NEJM Perspective pointing to more widespread use of masks by healthcare workers and even by individuals in the public sector.

COVID Infection Run Down with Dr. Kevin Winthrop

Dr Kevin Winthrop answers COVID questions and advocates for "hit the pause button, lay low and exercise". We discuss the utility of baricitinib, losartan, COVID testing, Next Success and who to listen to.

Dr. Artie Kavanaugh - Don't Stop!

Drs. Cush and Kavanaugh discuss the downside of stopping hydroxychloroquine, DMARDs and biologics in lupus, RA and pregnancy.

Venom Peptide-Steroid Conjugate Effective in Collagen Induced Arthritis

Science Translational Medicine features a report from the Fred Hutchinson Cancer Research Center showing that a scopion venom peptide, coupled to steroid, can significantly reduce joint inflammation in a rat model of rheumatoid arthritis (RA).

ACR Releases Reproductive Health Guidelines for Rheumatic Diseases

Today, the American College of Rheumatology (ACR) published the 2020 Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. This is the first, evidence-based, clinical practice guideline related to the management of reproductive health issues for all patients with rheumatic diseases.