Nonsteroidal Anti-inflammatory Drug Use Among Persons With Chronic Kidney Disease in the United States

Laura Plantinga, ScM; Vanessa Grubbs, MD; Urmimala Sarkar, MD; Chi-yuan Hsu, MD; Elizabeth Hedgeman, MS; Bruce Robinson, MD; Rajiv Saran, MD; Linda Geiss, MS; Nilka Ríos Burrows, MPH; Mark Eberhardt, PhD; Neil Powe, MD

Disclosures

Ann Fam Med. 2011;9(5):423-430. 

In This Article

Abstract and Introduction

Abstract

Purpose Because avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended for most individuals with chronic kidney disease (CKD), we sought to characterize patterns of NSAID use among persons with CKD in the United States.
Methods A total of 12,065 adult (aged 20 years or older) participants in the cross-sectional National Health and Nutrition Examination Survey (1999–2004) responded to a questionnaire regarding their use of over-the-counter and prescription NSAIDs. NSAIDs (excluding aspirin and acetaminophen) were defined by self-report. CKD was categorized as no CKD, mild CKD (stages 1 and 2; urinary albumin-creatinine ratio of ≥30 mg/g) and moderate to severe CKD (stages 3 and 4; estimated glomerular filtration rate of 15–59 mL/min/1.73 m2). Adjusted prevalence was calculated using multivariable logistic regression with appropriate population-based weighting.
Results Current use (nearly every day for 30 days or longer) of any NSAID was reported by 2.5%, 2.5%, and 5.0% of the US population with no, mild, and moderate to severe CKD, respectively; nearly all of the NSAIDs used were available over-the-counter. Among those with moderate to severe CKD who were currently using NSAIDs, 10.2% had a current NSAID prescription and 66.1% had used NSAIDs for 1 year or longer. Among those with CKD, disease awareness was not associated with reduced current NSAID use: (3.8% vs 3.9%, aware vs unaware; P=.979).
Conclusions Physicians and other health care clinicians should be aware of use of NSAIDs among those with CKD in the United States and evaluate NSAID use in their CKD patients.

Introduction

Both over-the-counter and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in the United States.[1] General medicine textbooks[2–4] and nephrology subspecialty consensus guidelines (National Kidney Foundation)[5] recommend avoidance of NSAIDs (except aspirin and acetaminophen) for most patients with chronic kidney disease (CKD). Persons with CKD, however, are likely unaware of their disease[6] and may also be unaware that NSAIDs should be avoided. Additionally, those with CKD are likely to be older and have multiple comorbid conditions or symptoms that lead to increased use of NSAIDs.[7]

NSAIDs have been associated both with acute kidney injury in the general population[8] and with disease progression in those with CKD.[9] For those with CKD, the further decrease in volume of renal blood flow resulting from decreased prostaglandin synthesis can lead to acute kidney injury, sodium retention, edema, hypertension, and hyperkalemia.[10] Acute interstitial nephritis can cause kidney damage and reduced renal function in a small percentage of NSAID users.[11] Habitual NSAID abuse can lead to analgesic nephropathy, a condition that is often irreversible upon drug discontinuation.[12] Additionally, NSAIDs interact unfavorably with some commonly prescribed medications, including loop diuretics, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, leading to reduced effectiveness, along with increased risk of renal impairment.[13,14] Although epidemiologic studies have linked NSAID use to progressive CKD,[15] the risks of NSAIDs in patients with CKD, while supported by consensus and theoretical effect, remain less clearly established by evidence.

Despite the potential adverse renal effects of NSAIDs, little is known about the patterns of NSAID use among those with CKD in community settings. Here we estimate the prevalence and describe patterns of self-reported NSAID use among adults by CKD status using data from the community-based National Health and Nutrition Examination Survey (NHANES).

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