Prescribing Advice for GPs

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Drug induced kidney injury

The British Medical Journal has published the results of a retrospective case control cohort study that aimed to assess the risk of acute kidney injury in patients prescribed NSAIDs and diuretics, angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB).

The study reviewed data for 487,372 users of antihypertensive drugs using data from the UK Clinical Practice Research Datalink. Average follow up was 5.9 years with 2,215 cases of acute kidney injury identified.

Dual therapy of an NSAID with either a diuretic, an ACEI or an ARB was not associated with an increased risk of acute kidney injury. Triple therapy of NSAID and two of the antihypertensive drugs was associated with a statistically increased risk of acute kidney injury (rate ratio 1.31, 95% confidence interval 1.12 to 1.53). A secondary analysis identified that the greatest risk appears to be in the first 30 days of use (rate ratio 1.82, 1.35 to 2.46).

The authors conclude that, "increased vigilance may be warranted when diuretics and angiotensin converting enzyme inhibitors or angiotensin receptor blockers are used concurrently with NSAIDs".

The authors note some limitations in this study including accuracy of recording of acute kidney injury in the database systems, residual confounding in observational data and inability to correct of exposure to over the counter NSAIDs.

Action: Clinicians should be aware of this study. A more cautious approach with greater monitoring may be prudent in patients taking combinations of these antihypertensives when NSAID use is unavoidable.

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