Consider kidney risks before using an NSAID

As a hospital pharmacist, you will be asked more, which NSAID is preferred in patients with kidney disease?.. There is NOT a “safest” NSAID for the kidneys. You might’ve heard that short-acting NSAIDs (ibuprofen, etc) are least kidney toxic. But this isn’t supported by evidence.

The real key is to use the lowest NSAID dose for the shortest duration. Also avoid other risks, such as dehydration due to vomiting, excess diuresis from diuretics or SGLT2 inhibitors, etc.

Keep in mind, acute use of NSAIDs should be safe even for most patients with mild to moderate chronic kidney disease. But try to use acetaminophen first in patients with severe kidney disease, such as CrCl less than 30 mL/min, or multiple conditions that raise kidney injury risk (heart failure, diabetes, etc). Or consider a topical NSAID for mild osteoarthritis pain in smaller joints (hand, knee, etc), systemic absorption is low. If a higher-risk patient needs to continue a scheduled oral NSAID after discharge, ensure outpatient follow-up is scheduled. Advise checking kidney function and electrolytes within about 2 weeks.

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References

1. Harężlak T, Religioni U, Szymański FM, Hering D, Barańska A, Neumann-Podczaska A, Allan M, Merks P. Drug Interactions Affecting Kidney Function: Beware of Health Threats from Triple Whammy. Adv Ther. 2022 Jan;39(1):140-147.
2. Baker M, Perazella MA. NSAIDs in CKD: Are They Safe?. Am J Kidney Dis. 2020 Oct;76(4):546-557.
3. Kunitsu Y, Hira D, Morikochi A, Ueda T, Isono T, Morita SY, Terada T. Time until onset of acute kidney injury by combination therapy with "Triple Whammy" drugs obtained from Japanese Adverse Drug Event Report database. PLoS One. 2022 Feb 9;17(2):e0263682.

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