Over-the-counter analgesic use

NSAIDs, analgesics, antiplatelet drugs, and decline in renal function: a retrospective case-control study with SIDIAP database

INTRODUCTION

We aim to explore the association between NSAIDs consumption, Symptomatic Slow Action Drugs for Osteoarthritis (SYSADOA), analgesics, and antiplatelet drugs, and decline in renal function by estimated Glomerular Filtration Rate (eGFR).

METHODS

We performed a case-control study using the SIDIAP database in Catalonia. We considered defined cases, patients with an eGFR value ≤ 45 ml/min/1.73 m2 in the period 2010-2015 with a previous eGFR value ≥ 60, and no eGFR ≥ 60 after this period. Controls had an eGFR ≥ 60 with no previous eGFR < 60. Five controls were selected for each case, matched by sex, age, index date, Diabetes Mellitus and Hypertension. We estimated Odds Ratios (OR, 95% Confidence Intervals) of decline in renal function for drugs group adjusting with logistic regression models, by consumption measured in DDD. There were n = 18,905 cases and n = 94,456 controls. The mean age was 77 years, 59% were women. The multivariate adjusted model showed a low risk for eGFR decline for NSAIDs (0.92;0.88-0.97), SYSADOA (0.87;0.83-0.91) and acetaminophen (0.84;0.79-0.89), and an high risk for metamizole (1.07;1.03-1.12), and antiplatelet drugs (1.07;1.03-1.11). The low risk in NSAIDs was limited to propionic acid derivatives (0.92;0.88-0.96), whereas an high risk was observed for high doses in both acetic acid derivatives (1.09;1.03-1.15) and Coxibs (1.19;1.08-1.30). Medium and high use of major opioids shows a high risk (1.15;1.03-1.29). Triflusal showed high risk at medium (1.23;1.02-1.48) and high use (1.68;1.40-2.01).

CONCLUSION

We observed a decline in renal function associated with metamizole and antiplatelet agent, especially triflusal, and with high use of acetic acid derivates, Coxibs, and major opioids. Further studies are necessary to confirm these results.

The case for cautious consumption: NSAIDs in chronic kidney disease

PURPOSE OF REVIEW

Strong epidemiological and pathologic evidence associates NSAIDs with kidney disease, both acute and chronic. Hence, the usage of NSAIDs has decreased in patients with, or at risk for, chronic kidney disease (CKD). Coupled with this has been a rise in use of opioids and other non-NSAID alternatives, which do come with significant, and underrecognized, risk of nonrenal adverse events. We review the literature to understand if this shift is appropriate or deleterious.

RECENT FINDINGS

NSAIDs do have a low but tangible risk in causing acute kidney injury, electrolyte imbalances, and increasing blood pressure. However, their role in causing progressive kidney disease is due to long-term usage in high cumulative dosages, and the use of NSAIDs in combination with other agents. Alternatives such as opioids, tramadol, gabapentin and baclofen have weak evidence to support their use and strong evidence to show their harm in patients with CKD.

SUMMARY

Tradeoffs are inherent in using active pharmaceuticals, and NSAIDs are no exception. Balancing potential benefits with possible adverse effects around pain management should be a part of every conversation for patients with kidney disease.

Non-steroidal anti-inflammatory drug effects on renal and cardiovascular function: from physiology to clinical practice

Excessive or inappropriate use of non-steroidal anti-inflammatory drugs can affect cardiovascular and renal function. Non-steroidal anti-inflammatory drugs, both non-selective and selective cyclooxygenase 2 inhibitors, are among the most widely used drugs, especially in the elderly, with multiple comorbidities. Exposition to a polypharmacy burden represents a favourable substrate for the onset of non-steroidal anti-inflammatory drug-induced deleterious effects. Cardiovascular and renal issues concerning the occurrence of myocardial infarction, atrial fibrillation, heart failure and arterial hypertension, as well as acute or chronic kidney damage, become critical for clinicians in their daily practice. We discuss current available knowledge regarding prostanoid physiology in vascular, cardiac and renal systems, pointing out potential negative non-steroidal anti-inflammatory drug-related issues in clinical practice.

Drug-Induced Kidney Injury in the Elderly

The incidence of acute kidney injury in the elderly has grown over the past decade. One of the primary drivers is drug-induced nephrotoxicity, which is the result of a combination of the unique susceptibilities to kidney injury and the increased use of medications in the elderly population. Specific drug classes are associated with increased rates of kidney injury including agents that block the renin angiotensin system, antimicrobials, and chemotherapeutic agents. Mechanistically, injury may be due to hemodynamic effects, tubular or glomerular toxicity, and interstitial nephritis. Early recognition of nephrotoxicity is critical, as are preventative steps when applicable. Unfortunately, treatment for established drug-induced kidney injury is limited and supportive care is required. Limiting exposure to nephrotoxic drugs is critical in decreasing the incidence of acute kidney injury in the elderly patient.

Common Analgesic Agents and Their Roles in Analgesic Nephropathy: A Commentary on the Evidence

An association between non-opioid analgesic agents and chronic kidney disease has long been suspected. The presumed development of chronic renal impairment following protracted and excessive use of non-opioid analgesia is known as analgesic nephropathy. Many clinicians accept analgesic nephropathy as a real entity despite the paucity of scientific evidence. This narrative review aims to summarize the literature in the field. The weight of available observational literature suggests that long-term ingestion of paracetamol and combination mixtures of aspirin and paracetamol are likely to contribute to chronic renal impairment. However, there is no convincing data to implicate non-steroidal anti-inflammatory drugs or aspirin monotherapy in the development of analgesic nephropathy. In the absence of high-level evidence, while controversy persists, it may be prudent for physicians to consider all non-narcotic analgesics to be nephrotoxic with long-term use.

Non-steroidal anti-inflammatories and the development of analgesic nephropathy: a systematic review

BACKGROUND

Analgesic nephropathy (AN) is chronic renal impairment as a direct consequence of chronic heavy analgesia ingestion. An association between non-steroidal anti-inflammatory agents and chronic kidney disease (CKD) has long been suspected. Despite ample observational data obtained in recent decades the relationship remains uncertain. This systematic review intends to summarize the available literature and to define the role of non-steroidal anti-inflammatories in the natural history of AN.

METHODS

We conducted a systematic literature search for articles describing the association between non-steroidal anti-inflammatory abuse and renal insufficiency. No restriction was placed on publication date, but papers were limited to English language, observational design, and human studies.

RESULTS

Nine articles met our inclusion criteria and were discussed in this review. This includes 5 cohort studies and 4 case-control trials, with a combined population of 12,418 study subjects and 23,877 controls. Eight of the nine reports failed to identify any increased risk of chronic renal impairment with heavy non-steroidal anti-inflammatory consumption. Study methods were heterogeneous and the overall quality of data was relatively poor.

CONCLUSION

A relationship between non-steroidal anti-inflammatory medicines and the development of CKD has never been proven. Based on the available scientific evidence non-steroidal anti-inflammatory agents do not appear to be implicated in the pathogenesis of AN.

Paracetamol and analgesic nephropathy: Are you kidneying me?

INTRODUCTION

Analgesic nephropathy is a disease resulting from the frequent use of combinations of analgesic medications over many years, leading to significant impairment of renal function. The observation of a large number of cases of renal failure in patients abusing analgesic mixtures containing phenacetin led to the initial recognition of the nephrotoxicity from the use of analgesics. Phenacetin was subsequently exclusively blamed for this disease. However, the role of a single analgesic as a sole cause of analgesic nephropathy was challenged, and a number of researchers have since attempted to determine the extent of involvement of other analgesics including nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and paracetamol.

CASE PRESENTATION

We present the case of an 83-year-old woman with a history of NSAID-induced nephropathy with poor pain control and reluctance to use paracetamol. We attempt to briefly review the evidence of paracetamol being implicated in the development of analgesic-induced nephropathy.

CONCLUSION

There is a lack of concrete data regarding causative analgesics, including paracetamol. Patients should therefore not be withheld paracetamol, an effective and commonly recommended agent, for fear of worsening renal function.

Increased risk of chronic kidney disease among users of non-prescribed Chinese herbal medicine in Taiwan

BACKGROUND

Taiwan has the highest incidence of chronic kidney disease (CKD) and end-stage renal disease (ESRD) worldwide. Chinese herbal medicine (CHM) has been linked to CKD/ESRD in Taiwan. The specific effects and frequency of CHM on the risk of CKD are unknown.

METHODS

A hospital-based case-control study was performed from August 2006 through December 2009. The cases were consecutive nephrology outpatients 20years of age or older, with a first-time diagnosis of CKD, and without cancer or pre-existing renal disease. The controls were randomly selected outpatients that did not have CKD and were matched 1:1 to cases for age, gender and date of outpatient visit.

RESULTS

Four hundred and twenty-four patients were recruited. Among 212 cases, 23.6% took non-prescribed CHM, compared to 6.6% among the controls (p<0.001). Multivariate analysis showed that illiteracy [odds ratio (OR) 6.3, 95% confidence interval (CI) 2.4-16.6], hypertension (OR 5.4, 95% CI 2.9-9.8) and occasional use of non-prescribed CHM (OR 6.2, 95% CI 1.8-21.6) were positively associated with CKD, whereas regular exercise was inversely associated with CKD (OR 0.5, 95% CI 0.3-0.9).

CONCLUSION

Occasional use of non-prescribed CHM was associated with the risk of CKD in Taiwan.

Nonsteroidal anti-inflammatory drug use among persons with chronic kidney disease in the United States

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 m(2)). 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.

Regular use of nephrotoxic medications is an independent risk factor for chronic kidney disease--results from a Chinese population study

BACKGROUND

Prescription drug abuse is an important global health concern. Our previous survey in Beijing indicates that nephrotoxic medication use is independently associated with chronic kidney disease (CKD).

METHODS

In the present study, the study population consisted of participants from our previous survey with a confirmed history of nephrotoxic medication use. Nephrotoxic mediations included three antipyretic analgesics (58.2%) and three Chinese traditional medicines containing aristolochic acids (CTM-AAs, 47.3%). Prevalence of CKD (defined by presence of albuminuria and/or reduced estimated glomerular filtration rate) as well as markers of tubular injury was analysed, and compared with 109 age- and sex-matched controls.

RESULTS

The prevalence of CKD was higher among medication users compared with controls, which was 18.3% and 8.5%, respectively. Among participants with medication use without CKD, markers of tubular injury including N-acetyl-β-d-glucosaminidase, transferrin and α(1)-microglobulin, were present in 26.6%. CKD was associated with CTM-AA use (cumulative AA-I dose > 0.5 g, OR = 5.625, P < 0.05) and antipyretic analgesic use (cumulative dose > 2.0 kg, OR = 3.848, P = 0.063) in a dose-dependent manner. Albuminuria and tubular injury persisted among CTM-AA users, but not among analgesic users after cessation of drug.

CONCLUSIONS

Our study suggests that education about rational analgesic use and CTM-AA banning may constitute an effective CKD prevention strategy.

Effects of 2-bromoethanamine on TonEBP expression and its possible role in induction of renal papillary necrosis in mice

Chronic analgesic abuse has been shown to induce severe renal injury characterized by renal papillary necrosis (RPN), an injury detectable at late stage. While direct toxicity of the drug may exist, the molecular mechanisms underlying analgesics induction of RPN remain unknown. A major limitation to study the pathogenesis of RPN is the required chronic exposure before detection of injury. Here, we employed 2-bromoethanamine (BEA) to simulate rapid papillary toxicity using inner medullary collecting duct (IMCD3) cells. Although exposure to 10μM BEA had no effect on cellular viability under isotonic conditions, a 50% loss in cell viability was observed in the first 24 h when cells were subjected to sublethal hypertonic stress and nearly complete cell death after 48 h suggesting that BEA exerts cytotoxicity only under hypertonic conditions. Because TonEBP is a transcription factor critical for cell survival during hypertonic conditions, we undertook experiments to examine the effect of BEA on TonEBP expression and activity. Exposure of cells to 10μM BEA resulted in a substantial reduction in TonEBP protein expression after 24 h. In addition, TonEBP was not translocated to the nucleus in BEA-treated IMCD3 cells under acute hypertonic stress for transcription of target genes essential for osmolyte accumulation. Finally, we found a substantial decrease in TonEBP expression in medullary kidney tissues of mice injected with a single ip dose of BEA. Our data suggest that TonEBP is a potential target for BEA leading to the process of papillary necrosis in the settings of hypertonic stress.

Nonsteroidal Anti-Inflammatory Drugs and the Kidney

Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit the isoenzymes COX-1 and COX-2 of cyclooxygenase (COX). Renal side effects (e.g., kidney function, fluid and urinary electrolyte excretion) vary with the extent of COX-2-COX-1 selectivity and the administered dose of these compounds. While young healthy subjects will rarely experience adverse renal effects with the use of NSAIDs, elderly patients and those with co-morbibity (e.g., congestive heart failure, liver cirrhosis or chronic kidney disease) and drug combinations (e.g., renin-angiotensin blockers, diuretics plus NSAIDs) may develop acute renal failure. This review summarizes our present knowledge how traditional NSAIDs and selective COX-2 inhibitors may affect the kidney under various experimental and clinical conditions, and how these drugs may influence renal inflammation, water transport, sodium and potassium balance and how renal dysfunction or hypertension may result.