GPAtlas🧭 When to suspect (and the prescribing decision)
Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit cyclo-oxygenase (COX), reducing prostaglandin synthesis. The same mechanism that relieves pain and inflammation drives their three signature harms – to the gastrointestinal (GI) tract, the cardiovascular (CV) system, and the kidneys.
The core discipline in primary care:
• Assess GI, CV and renal risk in every patient before starting an NSAID
• Use the lowest effective dose for the shortest duration
• Review the ongoing need regularly
There is no "safe" NSAID – only a safer choice for a given patient.
Suspect NSAID-related harm in a current user presenting with:
• Dyspepsia, epigastric or abdominal pain
• Signs of GI bleeding
• Worsening asthma
• New or worsening hypertension
• Fluid retention
• A falling estimated glomerular filtration rate (eGFR)
| Gastrointestinal risk | Cardiovascular risk | Renal risk (and volume) |
|---|---|---|
|
• Age 65 or over • Previous peptic ulcer or GI bleed • Concurrent anticoagulant, antiplatelet, selective serotonin reuptake inhibitor (SSRI) or corticosteroid • Helicobacter pylori infection • High dose, two NSAIDs together, or prolonged use; heavy alcohol intake |
• Heart failure • Hypertension • Established ischaemic heart disease (IHD), cerebrovascular disease or peripheral arterial disease (PAD) • Diabetes, hyperlipidaemia or smoking • High dose or prolonged use |
• Older age • Heart failure, volume depletion or dehydration • Concurrent angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) plus a diuretic (the "triple whammy") • Cirrhosis with ascites • Chronic kidney disease (CKD), especially eGFR < 60 |
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