Over-the-counter and under-the-radar: use of NSAIDs among people with kidney disease is common and could be harmful

NSAIDs, or non-steroidal anti-inflammatory drugs, are widely available over-the-counter, including ibuprofen (Advil™, Motrin™), naproxen (Aleve™, Anaprox™), and aspirin. These medications are primarily used as pain relievers (“analgesics”) and fever reducers. Additionally, many multi-drug formulations, like medicines for colds and menstrual symptoms, also contain NSAIDs.

Many NSAIDs are sold over-the-counter.

It is easy to forget that medications available over-the-counter are not without side effects and that they may not be safe for everyone. A recent community-based study (1) showed that NSAID use was common and that those with kidney disease were twice as likely to use NSAIDs frequently than those without kidney disease. This is despite the recommendation of the National Kidney Foundation (NKF) that people with kidney disease avoid NSAIDs because the effects of renal clearance of these drugs may be associated with kidney injury and progression of kidney disease. [Note that acetaminophen (Tylenol™) does not have the same type of clearance and is not considered risky in those with kidney disease.]

NSAIDs interact with several prescription drugs.

Additionally, NSAIDs may lessen the effectiveness of prescription drugs frequently taken by those with kidney disease, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and diuretics, all of which are taken to control blood pressure and prevent progression of disease. According to Vanessa Grubbs, MD, a nephrologist with the University of California, San Francisco, and co-author on the paper, “Primary care clinicians and doctors who prescribe medicine for pain management need to be aware of the potential interactions of NSAIDs with ACE inhibitors, ARBs, and loop diuretics.”

About 26 million people in the United States have early stages of kidney disease and >500,000 are currently treated with dialysis or have a kidney transplant because their kidneys have failed. Costs for kidney disease care make up about one-third of the Medicare budget. Thus, preventing and slowing the progression of CKD in the United States is essential, and educating patients and providers about the potential risks of NSAIDs is a way to improve patient outcomes.

What can you, as a patient, do about this potential risk?

First, know your risk for kidney disease. Other studies (2) have shown that most people with kidney disease are unaware of their disease. Kidney disease is often “silent” (=no symptoms) until it has progressed to late stages. Thus, knowing your risk allows you to ask your doctor for simple tests (serum creatinine and urine protein) that can assess possible damage to or reduced function of the kidneys. The most common risk factors for kidney disease are:

1. Diabetes

2. Hypertension

3. African-American, Hispanic, Pacific Islander, or Native American race/ethnicity

4. Family history

5. Older age

6. Inherited and autoimmune conditions such as glomerulonephritis and lupus

Second, if you have, or at high risk for, kidney disease, don’t assume that a drug is safe for you because it is available over-the-counter. There are explicit warnings on NSAIDs bottles about the increased risk of stomach ulcers/bleeding and cardiovascular events, but no such warnings regarding risk for kidney injury and disease progression appear on the bottle, despite calls for this labeling from the NKF >10 years ago. For any over-the-counter drug, read the entire label, including that insert inside the box that most of us throw away. You should consider asking your doctor about any drug or supplement you take over-the-counter, but specifically any that contain warnings about kidney or “renal” risks or describe the drug as having “renal clearance.”

What can health care providers do?

First, health care providers should test their high-risk patients regularly for kidney disease and talk to their patients about their risk. NSAIDs should be prescribed only as needed in those with or at high risk and after careful weighing of the risks and benefits. For example, a patient with debilitating arthritis may need pain relief for an acceptable quality of life, despite the potential risks.

Second, providers should carefully assess the use of over-the-counter NSAIDs in their patients. While patients often list the drugs they are taking as part of their visit, they may not consider over-the-counter NSAIDs as “drugs” or may forget about drug formulations that they take intermittently, such as cold medications. Also, some patients with low health literacy or problems with their vision may not be able to recall names of medications, which could lead to an ethical issue, if such vulnerable patients receive less-than-optimal advice. Providers may want to consider instead presenting a series of photos of various types of medication packaging that  contain NSAIDs so that the patient can identify the drugs they’ve taken rather than having to list the names of the medications.

About the author

Laura Plantinga, Sc.M., is a researcher whose interests include kidney disease awareness and outcomes. She is currently working on a doctoral degree in epidemiology at Emory University and setting a world record for oldest graduate student.

References
1. Plantinga L, Grubbs V, Sarkar U, Hsu CY, Hedgeman E, Robinson B, Saran R, Geiss L, Burrows NR, Eberhardt M, Powe N; CDC CKD Surveillance Team. Nonsteroidal anti-inflammatory drug use among persons with chronic kidney disease in the United States. Ann Fam Med. 2011;9(5):423-30.
2. Plantinga LC, Tuot DS, Powe NR. Awareness of chronic kidney disease among patients and providers. Adv Chronic Kidney Dis. 2010 May;17(3):225-36.

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