NSAIDs

In 1998, the American Geriatrics Society (AGS) Panel on Chronic Pain in Older Persons²⁴ specifically addressed the use of NSAIDs in the elderly population, and included the following recommendations:

High-dose, long-term NSAID use should be avoided When used chronically, NSAIDs should be used as needed, rather than daily or around the clock Short-acting NSAIDs may be preferable to avoid dose accumulation NSAIDs should be avoided in patients with abnormal renal function NSAIDs should be avoided in patients with a history of peptic ulcer disease NSAIDs should be avoided in patients with a bleeding diathesis The use of more than one NSAID at a time should be avoided

Ceiling dose limitations should be anticipated (i.e., maximum dose may be unattainable because of toxicity or may be accompanied by lack of efficacy).

The risk of gastrointestinal (GI) bleeding associated with NSAID use in the general population is about 1%. For those aged 60 or older, the risk reaches 3-4%, and for those aged 60 or older with a history of GI bleeding, the risk is about 9%.²⁴ Risk factors associated with a higher risk of gastrointestinal problems with NSAIDs include: age >= 65 years, history of peptic ulcer disease or of upper GI bleeding, previous NSAID-induced gastropathy, concomitant disease (especially cardiovascular), concomitant use of prednisone or anticoagulants, and concomitant use of two NSAIDs.²⁹

NSAIDs inhibit platelet aggregation, and caution must be used when administering NSAIDs concomitantly with warfarin and other anticoagulants. NSAIDs may have adverse hepatic, dermatologic, and central nervous system effects, especially in the frail elderly. Although prostaglandins have little role in maintaining renal function in normal individuals, prostaglandins are known to help maintain renal blood flow in patients who are renally compromised. Therefore elderly patients with impaired renal function, and especially those who often have comorbidities such as congestive heart failure (CHF) and hypertension may be at risk for additional renal compromise with NSAID therapy.²⁶, ³⁰

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