Use of non-steroidal anti-inflammatory drugs (NSAIDs) for musculoskeletal pain not linked with adverse outcomes in high risk groups

1. In this retrospective cohort analysis, patients with a history of hypertension, chronic kidney disease, or heart failure presenting to primary care physicians for musculoskeletal complaints were frequently prescribed NSAIDs.

2. Use of NSAIDs amongst high risk patients did not have any increased risk of cardiovascular or renal safety outcomes in short-term evaluation.

Evidence Rating Level: 3 (Average)       

Study Rundown: The management of common musculoskeletal (MSK) pain includes non-steroidal anti-inflammatory drugs (NSAIDs) as frontline pharmacologic therapy. Many guidelines recommend against NSAIDs in patients with renal or vascular disease due to concern of precipitating adverse events. The frequency of NSAID use and the prevalence of safety related events following their use is not well known. This study is a retrospective cohort study of patients with a history of hypertension, congestive heart failure (CHF), or chronic kidney disease (CKD) who presented to primary care providers for MSK complaints. The study found that prescriptions for NSAIDs were common following the initial clinic visit, but rates of cardiac and renal complications were not increased compared to matched controls.

The main strengths of the study included its large size of patients with fairly complete administrative records. The limitations of the study included lack of specific clinical data beyond diagnostic codes, and the lack of data on non-prescription medication use.

Click to read the study in JAMA Internal Medicine

Relevant Reading: Restricted Access Patterns of NSAIDs Use and Their Association with Other Analgesic Use in CKD

In-Depth [retrospective cohort]: This study is a retrospective cohort using administrative health databases and Ontario Health Insurance Plan (OHIP) claims. The study included patients who presented to a primary care provider for a MSK disorder in Ontario between 2012 and 2016. Patients were included if they had a diagnosis of hypertension, CKD, or CHF with 365 days of their visit. Patients younger than 65 years old, those without provincial health coverage, and long-term care residents were excluded.

The study included 2,415,291 musculoskeletal-related primary care visits for patients with hypertension, CKD, or CHF, and 9.3% of visits were associated with an NSAID prescription. The rate of short-term complications was not significantly different between those who had NSAID prescriptions and those that did not: cardiac complications (288 [0.8%] vs 279 [0.8%]), renal complications (34 [0.1%] vs 33 [0.1%]), and death (27 [0.1%] vs 30 [0.1%]).

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