Editorial Takeaway
Evidence for NSAID-related adverse effects is conflicting and of poor quality. They are likely safer than previously thought.
Key Opinions
- NSAIDs or COX-2 inhibitors should be administered routinely unless there are well-founded contraindications.
- Some studies suggest NSAIDs may increase the risk of acute kidney injury and persistent postoperative pain - but not with short-term perioperative use.
- An association was found between perioperative NSAID use and continued opioid use at 90 and 180 days post-surgery.
Editorial Excerpts
recent studies suggest that NSAID use can increase the risk of AKI and the incidence of persistent postoperative pain and persistent postoperative opioid use. However, evidence suggests that many of these concerns are unfounded, particularly with short-term perioperative use.
2018 Cochrane review of RCTs and quasi-RCTs concluded that in patients with normal renal function, the risk of postoperative AKI from perioperative NSAID use is uncertain despite a slight increase in postoperative serum creatinine concentrations, because the need for renal replacement therapy and hospital length of stay were not increased
causes of postoperative AKI are complex and multifactorial. Also, the pathophysiological changes in the perioperative period are complex and dynamic, and variability in perioperative care between institutions and countries would influence postoperative outcomes including postoperative renal function
the association between NSAIDs and increased risk of AKI does not infer causation. Thus, the current evidence for NSAID-induced AKI remains inconclusive.
Concerns regarding potential adverse effects associated with NSAIDs and COX-2-specific inhibitors are exaggerated based on available evidence owing to misapplication and misinterpretation of the current clinical literature. Evidence for these adverse effects is conflicting and of poor quality.
it is imperative that NSAIDs or COX-2-specific inhibitors are administered unless there are contraindications such as the presence of renal risk factors (e.g. impaired renal function, use of nephrotoxic agents or diuretics, and hypovolaemia), significant gastrointestinal bleeding risk factors, and acute cardiovascular disease. Procedures where even minimal bleeding can influence outcomes (e.g. closed cavity surgery such as neurosurgery, plastic surgery) should preclude NSAID use, but not use of COX-2-specific inhibitors.
Summary
"Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase (COX)-2-specific inhibitors provide significant analgesic and opioid-sparing benefits. However, these analgesics are commonly avoided owing to concerns of potential adverse effects. The evidence for NSAID-related adverse effects is conflicting and of poor quality, and these analgesics are safer than what has been implied. Thus, it is imperative that NSAIDs or COX-2-specific inhibitors are administered routinely unless there are well-founded contraindications."
Citation
Joshi GP, Kehlet H, Lobo DN. Nonsteroidal anti-inflammatory drugs in the perioperative period: current controversies and concerns. Br J Anaesth. 2024 Nov 28:S0007-0912(24)00652-4. doi: 10.1016/j.bja.2024.10.018. Epub ahead of print. PMID: 39613528.
