Advertisement

International Journal of Clinical Pharmacy

, Volume 34, Issue 3, pp 468–474 | Cite as

Effects of short-term addition of NSAID to diuretics and/or RAAS-inhibitors on blood pressure and renal function

  • Peder NygårdEmail author
  • Frank G. A. Jansman
  • Willemien J. Kruik-Kollöffel
  • Alex F. W. Barnaart
  • Jacobus R. B. J. Brouwers
Research Article

Abstract

Background The combined post-operative use of diuretics and/or renin-angiotensin-aldosterone system (RAAS) inhibitors may increase the risk of nonsteroidal anti-inflammatory drug (NSAID) associated renal failure because of a drug–drug interaction. Objective The aim of this study was to investigate the effect of the short-term (<4 days) post-operative combined use of NSAIDs with diuretics and/or RAAS inhibitors on renal function and blood pressure. Setting One teaching hospital in the Netherlands. Method The study-design was a prospective, observational cohort-study. Based on postoperative treatment with NSAIDs, the intervention-group was compared to a control-group (no NSAIDs treatment). Main outcome measure Systolic blood pressure and renal function expressed by the estimated glomular filtration rate (eGFR) calculated with the modification of renal desease formula. Results 97 patients were included in the intervention-group, 53 patients in the control-group. Patient characteristics were comparable except for one variable: ‘combined use of a diuretic with a RAAS inhibitor’ which was higher in the control-group (62 vs. 43 %, p = 0.046). Odds ratio for clinically relevant increase in systolic blood pressure was 0.66 (CI95 % 0.3–1.5). Odds ratio for clinical relevant decrease in renal function was 2.44 (CI95 % 1.1–5.2). On day 4 eGFR of 3 patients in the intervention- and 1 in the control-group was <50 ml/min/1.73 m2. Conclusion Odds ratios showed no significant difference of a clinically relevant increase in systolic blood pressure but showed a higher risk for a clinically relevant decrease in renal function in the intervention group. However this decrease resulted in a relevant impaired renal function (<50 ml/min/1.73 m2) in only 3 patients in the interventiongroup and 1 patient in the control-group. In the post-operative patient, without preexisting impaired renal function, concurrent diuretics and/or renin-angiotensinaldosterone system inhibitor therapy can be combined with short-term NSAID treatment.

Keywords

Blood pressure Diuretics Drug interaction NSAID RAAS inhibitors Renal insufficiency 

Notes

Acknowledgments

The authors would like to thank all patients who participated in the study. Special thanks go to R. Saleem for her work in including patients and gathering data. We are grateful to M. Arbouw and W. van der Zwet for their help with the statistical analysis.

Funding

The work was funded by the Deventer Ziekenhuis, Deventer, The Netherlands.

Conflicts of interest

None.

References

  1. 1.
    Fijn R, Koorevaar RT, Brouwers JRBJ. Prevention of heterotopic ossification after total hip replacement with NSAIDs. Pharm World Sci. 2003;25(4):138–45.PubMedCrossRefGoogle Scholar
  2. 2.
    Duyvendak M, van Roon EN, Naunton M, Bosman J, Klopotowska J, Brouwers JRBJ. Peri-operative drug management: clinical pharmacy services reduce potential drug related problems in orthopedic patients. Chapter 6 In: Pharmaceutical care by clinical pharmacists in patients with muskuloskeletal disease. Thesis Duyvendak M, Groningen, The Netherlands; 2010 p. 113–127. ISBN:978-90-367-4538-3.Google Scholar
  3. 3.
    Aronson JK. Side effects of drugs annual 32. Amsterdam: Elsevier; 2010.Google Scholar
  4. 4.
    White B. Cardiovascular effects of the cyclooxygenase inhibitors. Hypertension. 2007;49:408–18.PubMedCrossRefGoogle Scholar
  5. 5.
    Whelton A, Schulman G, Wallemark C, et al. Effects of celecoxib and naproxen on renal function in the elderly. Arch Intern Med. 2000;160:1465–70.PubMedCrossRefGoogle Scholar
  6. 6.
    Loboz KK, Shenfield GM. Drug combinations and impaired renal function—the ‘triple whammy’’. Br J Clin Pharmacol. 2004;59(2):239–43.CrossRefGoogle Scholar
  7. 7.
    Heerdink ER, Leufkens HG, Herings RM, et al. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med. 1998;158:1108–12.PubMedCrossRefGoogle Scholar
  8. 8.
    Scherning Olsen AM, Fosbol EL, Lindhardsen J, Folke F, Charlot M, Selmer C et al. Duration of treatment with NSAIDs drugs and impact on risk of death and recurrent myocardial infarction in patients with myocardial infarction: a nationwide cohort study. Circulation. 2011;123:2226–35.Google Scholar
  9. 9.
    Note for guidance on the evaluation of the pharmacokinetics of medicinal product in patients with impaired renal function. 23 June 2004. Available from http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/WC500003123.pdf.
  10. 10.
    Juhlin T, Jonsson BA, Hoglund P. Renal effects of aspirin are clearly dose-dependent and are of clinical importance from a dose of 160 mg. Eur J Heart Fail. 2008;10(9):892–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Meune C, Mourad JJ, Bergman JF, Spaulding C. Interaction between cyclooxygenase and the rennin-angiotensin-aldosterone system: rationale and clinical relevance. J Renin Angiotensin Aldosterone Syst. 2003;4(3):149–54.PubMedCrossRefGoogle Scholar
  12. 12.
    Traynor J, Mactier R, Geddes CC, Fox JG. How to measure renal function in clinical practice. BMJ. 2006;333:733–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Morgan TO, Anderson A, Bertram D. Effect of indomethacin on blood pressure in elderly people with essential hypertension well controlled on amlodipine or enalapril. Am J of Hypertens. 2000;13(11):1161–7.CrossRefGoogle Scholar
  14. 14.
    Shlipak MD, Sarnak MJ, Katz R. Cystatin C and the risk of death and cardiovascular events among elderly persons. N Engl J Med. 2005;352(20):2049–60.PubMedCrossRefGoogle Scholar
  15. 15.
    Groban L, Butterworth J. Perioperative management of chronic heart failure. Anesth Analg. 2006;103:557–75.PubMedCrossRefGoogle Scholar
  16. 16.
    Lee A, Cooper MC, Craig JC, Knight JF, Keneally JP. Effects of nonsteroidal anti-inflammatory drugs on postoperative renal function in adults with normal renal function (Review). Cochrane Libr. 2007;2:1–31.Google Scholar
  17. 17.
    Bouvy ML, Heerdink ER, Hoes AW, Leufkens HG. Effects of NSAIDs on the incidence of hospitalisations for renal dysfunction in users of ACE inhibitors. Drug Saf. 2003;26(13):983–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Levey SA, Bosch JP, Breyer Lewis J, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med. 1999;130:461–70.PubMedGoogle Scholar
  19. 19.
    Rule AD, Larson TS, Bergstralh EJ, et al. Using serum creatinine to estimate glomular filtration rate: accuracy in good health and in chronic kidney disease. Ann Intern Med. 2004;141:929–37.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2012

Authors and Affiliations

  • Peder Nygård
    • 1
    Email author
  • Frank G. A. Jansman
    • 2
    • 3
  • Willemien J. Kruik-Kollöffel
    • 2
  • Alex F. W. Barnaart
    • 4
  • Jacobus R. B. J. Brouwers
    • 3
  1. 1.Department of PharmacyDiaconessen Hospital Meppel & Bethesda Hospital HoogeveenMeppelThe Netherlands
  2. 2.Department of Clinical PharmacyDeventer HospitalDeventerThe Netherlands
  3. 3.Department of Pharmacotherapy and Pharmaceutical CareUniversity GroningenGroningenThe Netherlands
  4. 4.Department of OrthopaedicsDeventer HospitalDeventerThe Netherlands

Personalised recommendations