Clinical question: In patients with hypertension, chronic kidney disease, or heart failure presenting with a musculoskeletal disorder, how frequently are prescription NSAIDs dispensed and are there associated short-term (between 7-38 days of visit) safety-related outcomes?
Background: Multiple expert panels recommend against the use of NSAIDs in patients with hypertension (HTN), chronic kidney disease (CKD), or heart failure (HF). Previous studies have demonstrated an increased risk of cardiovascular events and renal injury with long-term NSAID use.
Study design: Retrospective cohort study.
Setting: Population-based administrative claims database identified primary care visits in Ontario.
Synopsis: Among 814,049 patients aged 65 years and older with high-risk medical conditions, 9.3% were prescribed NSAIDs. Of those prescribed NSAIDS, a vast majority had only HTN (90.8%). There was substantial variation in NSAID prescriptions among physicians (range 0.9%-69.2%; median, 11%). During the study period, there was a decline in the frequency of NSAID prescriptions. Those patients with reduced odds to receive an NSAID prescription had CKD, HF, hospitalization in the past year, or prior opiate use. Of 35,552 matched patient pairs either exposed or not exposed to NSAIDs (not controlled for disease severity), there was a similar rate of cardiac complications (288 vs. 279), renal complications (34 vs. 33), and death (27 vs. 30).
Patients with current opiate prescriptions were excluded. This study did not capture those patients taking ASA, over-the-counter formulations or topical NSAIDs.
Bottom line: NSAIDs are frequently prescribed among older adults with high-risk conditions, and short-term use of NSAIDs was not associated with increased cardiovascular or renal safety–related outcomes in this study. In otherwise healthy patients with HTN and musculoskeletal pain, it might be reasonable to trial a short course of NSAIDs with close monitoring.
Citation: Bouck Z et al. Frequency and associations of prescription nonsteroidal anti-inflammatory drug use among patients with a musculoskeletal disorder and hypertension, heart failure, or chronic kidney disease. JAMA Intern Med. 2018 Nov;178(11):1516-25.
Dr. Stanley is assistant professor of medicine at Northwestern University Feinberg School of Medicine and a hospitalist at Northwestern Memorial Hospital, both in Chicago.