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Preventing Acute Kidney Injury: Safe Use of NSAIDs, Diuretics, and ACEI/ARB

Learn to prevent acute kidney injury with safe NSAID, diuretic, and ACEI/ARB use in high-risk patients.

Triple Whammy Effect (NSAIDs, Diuretics, and ACEIs/ARBs)

Acute kidney injury (AKI) risk increases when combining NSAIDs with diuretics and ACE inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs). This "triple whammy" can severely impair kidney function, especially in patients over 65, with chronic kidney disease, or systolic heart failure. Dehydration from an acute viral illness further elevates this risk.

Preventing Acute Kidney Injury

Evaluate the patient's risk and necessity for each medication. Combining these drugs is generally safe in low-risk situations, such as patients with good renal function or those using occasional OTC NSAIDs or daily low-dose aspirin. Exercise caution with high-risk patients.

  • When possible, use alternatives like acetaminophen instead of an NSAID or a dihydropyridine calcium channel blocker (e.g., amlodipine) instead of a diuretic.
  • Dihydropyridines help manage NSAID-related BP increases, preserve renal blood flow, and pair well with an ACEI or ARB.

Monitor kidney function and serum potassium within a week of starting triple therapy, especially in high-risk patients. Advise high-risk patients to stay hydrated during acute viral illnesses to prevent dehydration.

Hold the diuretic and the ACEI or ARB if the patient becomes dehydrated or develops orthostatic hypotension. Advise immediate medical care if the patient shows signs of kidney problems, such as edema, low urine output, confusion, or nausea.

RxPharm-adv

Take-home points

Combining NSAIDs, diuretics, and ACEI or ARB increases AKI risk...

  1. Evaluate patient's risk and necessity before combining NSAIDs, diuretics, and ACEI or ARB.
  2. Use the combination safely in low-risk patients with good renal function.
  3. Opt for alternatives like acetaminophen or dihydropyridine calcium channel blockers in high-risk patients.
  4. Monitor kidney function and serum potassium within a week of starting triple therapy.
  5. Advise high-risk patients to stay hydrated, especially during acute viral illnesses.
  6. Hold diuretics and ACEI or ARB if dehydration or orthostatic hypotension occurs, and seek immediate medical care for kidney problem signs.

References

  1. Lapi F, Azoulay L, Yin H, Nessim SJ, Suissa S. Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study. BMJ. 2013;346:e8525. Published 2013 Jan 8. doi:10.1136/bmj.e8525
    2. Show more references

Keywords: NSAIDs, Diuretics, ACE inhibitors, ARBs, Acute kidney injury, Chronic kidney disease, Systolic heart failure, Dehydration, Serum potassium, Renal function

Senior clinical pharmacist, "Pharmacy Practice Department, Tanta University Hospital, Egypt". Medical content writer.