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Occasional NSAID Nuanced Approach CKD — ESENeph MCQ

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ModerateChronic Kidney DiseaseOccasional NSAID Nuanced Approach CKDESENeph

A 55-year-old man with CKD G4 on Ramipril asks about over-the-counter NSAIDs for occasional headache. He takes Ibuprofen 200 mg once every few weeks. Is occasional NSAID use acceptable?

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Correct answer: E — Very occasional, short-term, low-dose NSAID use may be acceptable in stable CKD G3-4 with adequate hydration and BP monitoring – but must be weighed against alternatives; Paracetamol should be tried first; the key risk is when combined with RASi and/or diuretics

The dogmatic prohibition of all NSAIDs in CKD is being nuanced. Very occasional use (once or twice monthly) of low-dose NSAIDs in stable CKD without volume depletion, heart failure, or concurrent diuretics/RASi may be reasonable when alternatives are inadequate. However: Paracetamol should always be tried first; the triple-whammy risk (NSAID + ACEi + diuretic) applies even to occasional doses; and patients should be counselled to avoid NSAIDs during illness, dehydration, or hot weather. Topical NSAIDs have lower systemic absorption and may be a safer alternative for musculoskeletal pain.

Reference: NICE CG182 – CKD; KDIGO 2024 – CKD; Lipworth et al 2013