Can NSAIDs Be Used Safely for Analgesia in Patients with CKD?: CON.

Abstract

Nonsteroidal anti-inflammatory drugs (NSAIDs) reversibly inhibit cyclooxygenase (COX) and therefore alter PG synthesis in many tissues with a range of effects beyond their intended one. NSAIDs have a number of well-known adverse effects on the kidney, gastrointestinal (GI) tract, and cardiovascular system. Adverse effect profiles vary by drug, in part depending on relative selectivity for the COX-1 and COX-2 isozymes, with more COX-2 selective inhibitors having lower risk of GI bleeding but higher risk of cardiovascular disease. Therefore, all NSAIDs have potentially serious adverse effects, and NSAIDs are a common cause of drug-related emergency hospital admission and drug-related death, from GI bleeding, AKI, and serious cardiovascular events (1,2). International consensus guidelines recommend avoiding NSAIDs in people with eGFR <30 ml/min per 1.73 m2, and to avoid prolonged use in those with eGFR 30–59 ml/min per 1.73 m2 (3). Despite this, NSAIDs are commonly prescribed to people with CKD. One in ten people with CKD in the Chronic Renal Insufficiency Cohort Study were prescribed an NSAID annually, with 24% exposed at some point during 8 years of follow-up. Exposure was common in all subgroups examined, but was somewhat less likely in people with more severe CKD and those seeing nephrologists (4). A systematic review of NSAID use in people with CKD in seven cross-sectional studies found that 8%–21% were currently taking NSAIDs (5). One likely reason for liberal prescribing is that NSAID prescribing has rapidly observable benefits on pain, whereas harms are merely theoretical risks at the point of prescribing. In addition, the prescriber will often not observe the harmful outcome because the patient presents with adverse effects elsewhere in the health care system. Randomized controlled trials examining NSAID effectiveness routinely exclude people with CKD, and often do not evaluate renal outcomes or other potential …