Risk of acute kidney injury when adding NSAID to diuretic plus ACEI or ARB
As a clinical pharmacist, you'll hear more about the risk of acute kidney injury when adding an NSAID to a diuretic plus an ACEI or ARB. Combining all three agents creates a "triple whammy" to impair kidney function and sometimes the kidneys can't compensate. This is especially true in patients at risk due to age over 65, chronic kidney disease, or systolic heart failure. Add dehydration from an acute viral illness to the mix and the risk of kidney problems jumps.
Think about patient's risk and the need for each medication. Feel fine with the combination in low-risk situations, such as patients with good renal function or those using only occasional OTC or topical NSAIDs, or daily low-dose aspirin. Use more caution with the combination in high-risk patients. When appropriate, use alternatives (acetaminophen instead of an NSAID) or a dihydropyridine calcium channel blocker (amlodipine, etc) instead of a diuretic. Keep in mind that dihydropyridines help block NSAID-related BP increases, preserve renal blood flow, and work well with an ACEI or ARB.
Monitor kidney function and serum potassium within a week of starting triple therapy especially in high-risk patients. If high-risk patients develop an acute viral illness, advise them to drink fluids to prevent dehydration.
Hold the diuretic and the ACEI or ARB if the patient becomes dehydrated or develops orthostatic hypotension. Advise immediate medical care if a patient develops signs of kidney problems edema, low urine output, confusion, nausea, etc.
References
- Lapi, F., Azoulay, L., Yin, H., Nessim, S.J. and Suissa, S. (2013). Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study. BMJ, 346(jan08 12), pp.e8525–e8525. Available at: https://www.bmj.com/content/346/bmj.e8525.
- Loboz KK, Shenfield GM. Drug combinations and impaired renal function - the 'triple whammy'. Br J Clin Pharmacol. 2005 Feb;59(2):239-43. Available at: https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/j.0306-5251.2004.2188.x.
