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 is to assess GI, CV and renal risk in every patient before starting an NSAID, use the lowest effective dose for the shortest duration, and 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, or 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
|
• 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 |
Source: NICE · MHRA
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