Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations

Abstract

BackgroundNon-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications.ObjectiveTo develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs.MethodsRandomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations.ResultsWhenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients 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.ConclusionNSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.

Psoriatic Arthritis and Diabetes Mellitus: A Narrative Review

“…NSAIDs have been further studied to be potentially beneficial in the prevention and treatment of diabetic subjects due to their action on glucose metabolism; more in detail, NSAIDs exert an anti-inflammatory effect on the pancreatic islets, reduce the metabolic clearance of insulin, and reduce the hepatic insulin resistance, leading to an enhanced peripheral glucose uptake and a reduced endogenous glucose production. NSAIDs are associated with some serious adverse effects, including hypertension and cardiovascular diseases [73,74]. Unfortunately, diabetic patients also have an increased risk of coronary artery disease and NSAIDs also seem to be associated with an increase in such risk.…”

Spezielle Schmerztherapie bei rheumatischen Erkrankungen

“…Neben gastrointestinalen und kardiovaskulären Risiken, sind renale und hepatische Nebenwirkungen zu beachten. Der Blutdruckanstieg unter NSAR Einnahme ist zwar meist gering ausgeprägt, könnte aber einen relevanten Beitrag zum Nebenwirkungsprofil bei chronischer ( > 4 Wochen) NSAR Therapie, v. a. im Hinblick auf kardiovaskuläre und renale Nebenwirkungen, leisten [26]. Insofern ist unter einer länger dauernden NSAR Therapie eine konsequente Blutdruckmessung und -einstellung wichtig.…”

“…Der Blutdruckanstieg, der bei allen NSAR Präparaten auftreten kann, ist dabei zwar meist eher gering ausgeprägt, 2-30 % der Patienten benötigen aber eine Anpassung der hypertensiven Therapie [27]. Patienten unter Therapie mit ACEoder Angiotensinrezeptor (AT)2 Blockern sind hier mehr gefährdet, weshalb bei Notwendigkeit der Anpassung der hypertensiven Therapie auf andere Wirkmechanismen zurückgegriffen werden sollte [26]. Die Auswahl des richtigen NSAR Präparats hängt von dessen pharmakologischen Charakteristika, aber auch von Patienten-individuellen Faktoren ab, v. a. Komorbiditäten.…”

“…Allerdings ist auch klar, dass eine vorbestehende Niereninsuffizienz unter Einnahme von NSAR verschlechtert werden kann mit einem durchschnittlichen, weiteren jährlichen GFR-Verlust von > 5 ml/min/1,73m2 [30]. Die Empfehlung lautet daher, NSAR bei einer GFR < 30 ml/min/1,73m2 zu vermeiden, aber auch bei einer leicht eingeschränkten GFR von 30-59 ml/min/1,73m2 unter laufender ACE-, AT2 Blocker Therapie keine NSAR zu kombinieren [26]. Wenn akute renale Schäden durch die NSAR Therapie auftreten, geschieht dies relativ schnell, meist innerhalb der ersten Therapiewoche, weshalb eine erste Kontrolle in diesem Intervall sinnvoll ist.…”

Covid-19—The real role of NSAIDs in Italy

“…The effects of this warning has been very deleterious on our patients, especially on those who need to use these drugs for long periods for their medical conditions: NSAIDs allow these patients to lead a good quality of life, although we acknowledge that the prolonged use of these drugs may cause side effects, including kidney failure, liver failure, gastric ulcers, asthma attacks, heart and circulatory problems, and a partial immune depression [4].…”