Panel releases evidence-based recommendations for safer NSAID prescriptions :- Medznat

Experts release multidisciplinary guidelines for safe NSAID use in high-risk patients

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A joint task force of 6 leading Asia-Pacific medical societies has released updated, evidence-based recommendations to support the safe use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with hypertension, cardiovascular, renal, or gastrointestinal (GI) comorbidities.

The initiative, led by the Asia-Pacific Association of Gastroenterology (APAGE), Asia Pacific League of Associations for Rheumatology (APLAR), Asia-Pacific Society for Digestive Endoscopy (APSDE), Asian Pacific Society of Hypertension (APSH), Asian Pacific Society of Nephrology (APSN), and the Pain of Asia (PoA) working group, aims to assist clinicians balance therapeutic benefits with potential risks.

The expert panel systematically reviewed available evidence—including 329 randomized controlled trials and observational studies published up to January 2018—to develop multidisciplinary, consensus-driven guidance for individualized NSAID therapy and improved patient safety.

1. General Principles

NSAIDs are widely used for pain and inflammation. But, they can trigger adverse effects involving the heart, kidneys, and GI tract. Experts recommend:

Using the lowest potent dose for the shortest duration possible.
Engaging in shared decision-making to weigh risks and benefits with patients.
Avoiding NSAIDs altogether in those with treatment-resistant hypertension, severe chronic kidney disease (CKD), or elevated cardiovascular risk.

2. Blood Pressure Management

Measure blood pressure (BP) before initiating therapy and monitor 4 weeks after starting or earlier if needed.
Monitor BP even during short-term therapy in patients with hypertension.
Encourage home BP and fluid retention monitoring (e.g., checking for pedal edema).
Avoid NSAIDs in those with resistant hypertension.
For hypertensive patients on angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), consider adding an antihypertensive of another class to counteract NSAID-induced BP rise.

3. Cardiovascular Safety

Avoid chronic NSAID therapy in those with a history of heart ailment or ischemic events.
If NSAIDs are unavoidable in high-risk individuals, naproxen or celecoxib is preferred due to a safer cardiovascular profile.
Diclofenac and rofecoxib carry a higher cardiovascular risk and must be avoided.
The risk of complications amplifies with longer duration and higher doses.

4. Renal Protection

Avoid NSAIDs in:
1. Those with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m² (severe CKD).
2. Those with moderate CKD (eGFR 30–59) receiving ACE inhibitors, ARBs, or diuretics.
Check renal function before initiating therapy in high-risk patients (if not done within the past 6 months).
Monitor kidney function 3–7 days after starting NSAIDs, and continue regular testing for chronic users.
Reassess renal function promptly if fluid retention, edema, or renal symptoms appear.
No specific NSAID has been proven safer for CKD patients.

5. GI Protection

For dyspepsia, use proton pump inhibitors (PPIs); antacids and H2 blockers are not efficient.
For moderate ulcer risk, use a non-selective NSAID + PPI or a cyclooxygenase-2 (COX-2) inhibitor alone.
For high ulcer risk, use a COX-2 inhibitor + PPI combination.
For those with unexplained iron-deficiency anemia, refer to a gastroenterologist before NSAID initiation and, if prudent, use celecoxib as the preferred agent owing to lower GI toxicity.

6. Monitoring and Follow-Up

Once NSAID therapy begins, continued surveillance is crucial:

Blood pressure and renal function must be regularly checked.
Monitor for GI symptoms such as dyspepsia or signs of bleeding.
Educate patients on warning symptoms (e.g., swelling, dark stools, shortness of breath).

7. Implementation and Awareness

Despite strong evidence, the authors highlight implementation barriers — NSAIDs are often prescribed by primary care physicians or surgeons, while complications are tackled by cardiologists, nephrologists, or gastroenterologists. To sum up, safe NSAID use demands a multidisciplinary approach — integrating cardiovascular, renal, and GI perspectives — to ensure optimal patient outcomes across diverse clinical settings.

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