Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations
- 14 January 2020
- Vol. 69 (4), 617-629
- https://doi.org/10.1136/gutjnl-2019-319300
Abstract
Background Non-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. Objective To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs. Methods Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations. Results Whenever 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. Conclusion NSAIDs 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.Keywords
Funding Information
- Pfizer
This publication has 207 references indexed in Scilit:
- Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trialsThe Lancet, 2013
- GI-REASONS: A Novel 6-Month, Prospective, Randomized, Open-Label, Blinded Endpoint (PROBE) TrialThe American Journal of Gastroenterology, 2013
- Cardiovascular safety of lumiracoxib: a meta-analysis of randomised controlled trials in patients with osteoarthritisEuropean Journal of Clinical Pharmacology, 2012
- Lansoprazole for secondary prevention of gastric or duodenal ulcers associated with long-term non-steroidal anti-inflammatory drug (NSAID) therapy: results of a prospective, multicenter, double-blind, randomized, double-dummy, active-controlled trialThe Esophagus, 2012
- Proton Pump Inhibitors Exacerbate NSAID-Induced Small Intestinal Injury by Inducing DysbiosisGastroenterology, 2011
- Use of Aspirin or Nonsteroidal Anti-inflammatory Drugs Increases Risk for Diverticulitis and Diverticular BleedingGastroenterology, 2011
- Subgroup analyses to determine cardiovascular risk associated with nonsteroidal antiinflammatory drugs and coxibs in specific patient groupsArthritis Care & Research, 2008
- Prevention of Ulcers by Esomeprazole in At-Risk Patients Using Non-Selective NSAIDs and COX-2 InhibitorsThe American Journal of Gastroenterology, 2006
- The Effects of Cyclooxygenase-2 Inhibitors and Nonsteroidal Anti-inflammatory Therapy on 24-Hour Blood Pressure in Patients With Hypertension, Osteoarthritis, and Type 2 Diabetes MellitusArchives of Internal Medicine, 2005
- Independent effects of residual renal function and dialysis adequacy on nutritional status and patient outcome in continuous ambulatory peritoneal dialysisAmerican Journal of Kidney Diseases, 1999