I. See Also

  1. NSAID
  2. NSAID Alternatives
  3. Nephrotoxicity

II. Epidemiology

  1. NSAIDs are top cause of Renal Insufficiency in elderly

III. Physiology

  1. NSAIDs decrease synthesis of renal prostaglandins
  2. Prostaglandins vasodilate renal vessels
  3. NSAIDs therefore reduce renal blood flow

IV. Risk Factors: NSAID related Acute Renal Failure

  1. Elderly
  2. Hypovolemia
  3. Ineffective circulation
    1. Congestive Heart Failure
    2. Cirrhosis
    3. Nephrotic Syndrome
  4. Concurrent medications
    1. ACE Inhibitor
    2. Angiotensin Receptor Blocker (ARB)
    3. Diuretics

V. Adverse Effects: General Renal effects

  1. NSAID Related Fluid and Electrolyte abnormalities
    1. Edema
    2. Hyperkalemia
  2. Acute Renal Failure
  3. Acute papillary Necrosis

VI. Management: Practice Guidelines for NSAID use in the elderly

  1. Establish a definitive treatment diagnosis
    1. Inflammatory condition (e.g. Rheumatoid Arthritis)
      1. NSAID indicated
      2. COX2 Inhibitor offers no advantage regarding nephrotoxicity
    2. Non-Inflammatory condition
      1. NSAID alternative medication (e.g. Tylenol)
  2. Perform baseline Renal Function and repeat q3-12 months
    1. See NSAIDs for lab monitoring
    2. Creatinine
    3. Consider screening for Proteinuria
  3. Choose NSAID with high benefit to risk ratio (e.g. Sulindac)
    1. Good efficacy
    2. Lower renal toxicity
  4. Avoid the most NSAIDS most commonly associated with nephrotoxicity
    1. Ketorolac (Toradol)
    2. Indomethacin
  5. Begin with lowest NSAID dose and use the lowest effective dose
  6. Consider Gastric protection or COX2 Inhibitor
    1. See NSAID Gastrointestinal Adverse Effects
  7. Continue to monitor efficacy and side effects
    1. Do no harm
  8. Avoid combining high risk medications
    1. Avoid using NSAID with another NSAID
  9. Avoid NSAIDs in reduced renal perfusion
    1. Avoid NSAIDs with ACE Inhibitors or Angiotensin Receptor Blockers
    2. Avoid NSAIDs with Diuretics
    3. Avoid NSAIDs in dehydration
  10. Avoid combinations predisposing to Hyperkalemia
    1. Avoid NSAID with potassium sparing Diuretic
    2. Avoid NSAID with ACE Inhibitor

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