Other Risky Situations

So far, we’ve discussed the best NSAID options for patients with cardiovascular (CV) risk factors (naproxen) (See Part 1) and gastrointestinal (GI) risk factors (ibuprofen, celecoxib, meloxicam or nabumetone) (See Part 2). But in hospice, we are often dealing with patients who are at risk of both CV and GI complications, and who may also have some degree of renal impairment, and who may also be taking meds that interact with NSAIDs, like ACE inhibitors or angiotensin receptor blockers (ARBs), diuretics, or low-dose aspirin. What are the best management strategies in these patients?

If your patient is at both CV and GI risk, choosing an NSAID will be a trade-off, and if you can, it’s probably prudent to avoid an NSAID. Exhaust your other options (like acetaminophen and opioids) first. But if you must use an NSAID, ibuprofen is probably your safest bet. GI risk is low relative to other options, and CV risk is only slightly higher than naproxen. However, you should add a proton-pump inhibitor or misoprostol for GI protection, and you should start with a low ibuprofen dose and try to stay there. If you must increase the dose, do so slowly, monitoring closely for worsening cardiovascular status—in particular, increased edema or blood pressure.

Another issue to keep in mind is the fact that patients with cardiovascular disease are often taking drugs that reduce renal perfusion, such as ACE inhibitors, ARBs and diuretics. Adding an NSAID to any two of these three is known as the “triple whammy” and can result in acute renal failure. The elderly and those with preexisting renal dysfunction are at increased risk. Think twice before adding an NSAID in this case, and try other pain relievers first. If you must use an NSAID, there is probably no one NSAID that will be better than any other, so stick with either naproxen (if GI risk is low) or ibuprofen (if GI risk is moderate-high). Maintain hydration, because dehydration further reduces renal blood flow. Make sure patients with heart failure weigh themselves daily (if possible) to detect any acute changes in fluid balance. You may want to consider monitoring the patient’s serum creatinine during initiation of NSAID therapy, and watch closely for signs of worsening kidney function (which MAY include decreased urine output, edema, confusion, lethargy, orthostasis, tachycardia, thirst/dry mouth). Discontinue at least one of the “triple whammy” agents if increased serum creatinine or signs of worsening renal function are noted.

In patients with kidney disease, there is a general concensus that NSAIDs should be avoided, because they have been associated with increased risk of progression to end-stage renal disease and acute renal failure. This risk is higher in the elderly and in patients who are hospitalized or acutely ill (pretty much every hospice patient!). However, clinicians are advised to consider the risks and benefits on a case-by-case basis, considering the patient’s renal status alongside the risks of potentially compromised pain control. Of course, try acetaminophen and opioids first, and if an NSAID must be used, start with a low dose and monitor closely for signs of worsening kidney function as described above. Also, keep an eye out for the “triple whammy”—many patients with kidney disease take diuretics and ACE inhibitors or ARBs, even if they don’t have heart disease.

For patients who are taking low-dose aspirin, NSAID administration needs to be scheduled so as not to interfere with aspirin’s antiplatelet activity. The NSAID should be dosed either 1 hour AFTER or at least 8 hours BEFORE aspirin, if possible. (Please note that, in general, we would recommend discontinuing low-dose aspirin in a hospice patient, but if the patient is going to continue using it, you may as well make sure it’s having some beneficial effect.)

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