NSAIDs in CKD: Are They Safe?

The management of pain in patients with chronic kidney disease (CKD) is challenging for many reasons. These patients have an increased susceptibility to adverse drug effects due to altered drug metabolism and excretion, and there are limited safety data for use in this population despite a high pain burden. Non-steroidal anti-inflammatory drugs (NSAIDs) have long been regarded as dangerous for use in chronic kidney disease patients because of their risk for nephrotoxicity, and thus alternative classes of analgesics, including opioids, have become more commonly used for pain control in this population. Given the well-established risks opioids and other analgesics pose, further characterization of the risk posed by NSAIDs in patients with CKD is warranted. NSAID use has been associated with acute kidney injury, progression of renal impairment in CKD, electrolyte derangements, and hypervolemia with worsening of heart failure and hypertension. The risk for these nephrotoxicity syndromes is modified by many comorbidities, risk factors, and characteristics of use, and in CKD patients the risk differs between levels of renal impairment. In this review, we offer recommendations for the cautious use of NSAIDs in the CKD population after careful consideration of these risk factors on an individualized basis.