Elderly patients NSAIDs

Approximately 8% to 20% of patients with UC and 7% to 26% of patients with CD are elderly at initial diagnosis.42 In general, IBD presents similarly in elderly patients compared to younger individuals. Elderly patients may have more comor-bid diseases, some of which may make the diagnosis of IBD more difficult. Such conditions include ischemic colitis, diverticular disease, and microscopic colitis. Increased age is also associated with a higher incidence of adenomatous polyps, but the onset of IBD at an advanced age does not appear to increase the risk of developing colorectal cancer. Elderly patients may also use more medications, particularly NSAIDs, which may induce or exacerbate colitis. 

Patients at increased risk of NSAID-induced gastrointestinal adverse effects (e.g., dyspepsia, peptic ulcer formation, and bleeding) include the elderly, those with peptic ulcer disease, coagulopathy, and patients receiving high doses of concurrent corticosteroids. Nephrotoxicity is more common in the elderly, patients with creatinine clearance values less than 50 mL/minute, and those with volume depletion or on diuretic therapy. NSAIDs should be used with caution in patients with reduced cardiac output due to sodium retention and in patients receiving antihypertensives, warfarin, and lithium. 

Systemic corticosteroids are a useful option in patients with contraindications to NSAIDs or colchicine (primarily renal impairment) or polyarticular attacks, especially in elderly patients. A single intramuscular injection of a long-acting corticosteroid such as triamcinolone hexacetonide may be used. Oral agents may be needed, especially for severe attacks. Prednisone 40 to 60 mg (or an equivalent dose of another agent) is given daily, with a gradual taper over 2 weeks. 

Although the risk of GI complications is relatively small with short-term therapy, coadministration with a proton pump inhibitor should be considered in elderly patients and others at increased GI risk. NSAIDs should be used with caution in individuals with a history of peptic ulcer disease, heart failure, uncontrolled hypertension, renal insufficiency, coronary artery disease, or if they are receiving anticoagulants concurrently. 

Gl risk NSAIDs cause an increased risk of serious Gl adverse reactions, including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These reactions can occur at any time during use and without warning symptoms. Elderly patients are at highest risk for serious Gl reactions. 

Corticosteroids are extremely useful in elderly patients who cannot tolerate full doses of NSAIDs. However, they consistently cause a dose- and duration-related increase in osteoporosis, an especially hazardous toxic effect in the elderly. It is not certain whether this drug-induced effect can be reduced by increased calcium and vitamin D intake, but it would be prudent to consider these agents (and bisphosphonates if osteoporosis is already present) and to encourage frequent exercise in any patient taking corticosteroids. 

Great care should be exercised in prescribing colchicine for elderly patients, and for those with cardiac, renal, hepatic, or gastrointestinal disease. In these patients and in those who do not tolerate or respond to colchicine, indomethacin or another nonsteroidal anti-inflammatory agents (NSAID) is preferred. 

The toxicity of aminoglycosides in the kidney and other organs is concentration-dependent. Antibiotics such as kanamycin and gentamycin have their half-lives doubled in elderly patients. The elderly commonly suffer from osteoarthritis and (less commonly) rheumatoid arthritis. NSAIDs must be carefully used in geriatric patients, as they cause GI toxicity. For example, aspirin causes GI irritation... 

The GP then added in indometacin, which compromised renal perfusion. The combination therapy of an NSAID, an ACE inhibitor and a diuretic in an elderly patient who because of his age already has reduced renal function, induced a state of acute renal failure. 

Side effects associated with the nonsalicylate NSAIDs are essentially those caused by salicylate therapy. NSAIDs occasionally cause CNS dysfunction, including decreased attention span, loss of short-term memory, confusion in elderly patients, and headache. 

One of the major problems with use of NSAIDs in elderly patients, especially women, is the increased incidence of gastric mucosal damage (NSAID gastropathy). This condition can lead to significant GI bleeding and... 

The use of NSAIDs to treat and prevent bladder spasms has been documented in clinical trials (114) and their role in relaxing bladder smooth muscle has experimental support (115). Three elderly patients who used rofecoxib or celecoxib developed acute but reversible urinary retention (116). Each had co-morbidities likely to cause bladder dysfunction, and the administration of a COX-2 inhibitor may have caused further relaxation of the detrusor muscle, resulting in urinary retention. 

Elderly patients are susceptible to the adverse effects of NSAIDs on the nervous system. A psychotic reaction has been described in one elderly man taking indometacin (57) and behavioral changes in another (58). 

Like many other NSAIDs, ketoprofen can cause acute interstitial nephritis (10). Renal insufficiency and the nephrotic syndrome due to membranous glomerulonephritis (an unusual cause of NSAID-induced nephrotic syndrome) have been described in an elderly patient taking long-term ketoprofen (SEDA-12, 86). 

There have been several reports of impaired renal function in patients taking ketorolac (SEDA-17, 112) (SEDA-18, 105) (SEDA-22, 117). The severity varies from slight to severe forms of renal insufficiency, which may even occur after a single dose of 30 mg. Because recent major surgery is considered a risk factor for renal insufficiency, particularly in elderly patients, the use of ketorolac, or other NSAIDs, for postoperative pain management is warranted only in carefully selected patients. Furthermore, a case report confirmed that oral ketorolac can cause acute renal insufficiency in young subjects without any predisposing factors (SEDA-21,106). 

Data on the safety of loxoprofen are based on an open, multicenter trial of about 4000 elderly patients in Japan (SEDA-17, 112). Adverse effects were mainly gastrointestinal, but other adverse effects, common to every NSAID, included edema, dizziness, skin rashes, pruritus, and a case of eosinophilic pneumonia and liver dysfunction (SEDA-17,112). 

Whether these results apply with certainty to patients taking NSAIDs is not known, because these studies included patients not taking NSAIDs, but it is wise to consider this probability. The type and dose of NSAID may be important, but more studies are needed to document this. Hypertensive and elderly patients seem to be particularly at risk. In patients taking long-term NSAIDs, or even paracetamol, periodic monitoring of blood pressure appears to be warranted. 

In 600 elderly patients with documented congestive cardiac failure there was a possible or probable link between NSAIDs and heart failure in 27 cases (32). In some, the mechanism was apparently a reduction in the effect of furosemide. In others the NSAID may have caused an imbalance in circulatory homeostasis. Preexisting renal impairment was not observed in any of the 27 cases. This study suggests that in elderly people congestive heart failure may be a complication of NSAIDs. 

Taking into account the limitations of these studies (SEDA-22, 110), these results should not lead to uncritical prescription of proton pump inhibitors for primary prophylaxis in patients taking NSAIDs. Prophylactic therapy may be justified only in high-risk patients, such as the elderly, patients with a history of peptic... 

Heerdink ER, Leufkens HG, Herings RM, Ottervanger JP, Strieker BH, Bakker A. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med 1998 158(10) 1108-12. 

Page J, Henry D. Consumption of NSAIDs and the development of congestive heart failure in elderly patients an underrecognized public health problem. Arch Intern Med 2000 160(6) 777-84. 

Patients with sodium depletion are at risk of developing hyponatremia with aU NSAIDs. Sulindac also provoked hyponatremia in an elderly patient taking a salt-restricted diet (47). 

Edema due to NSAIDs induced sodium and fluid retention usually occurs in susceptible individuals within the first week of therapy. Furthermore, these effects are reversible when the drug is discontinued. Clinically evident peripheral edema occurs in up to 5% of patients [3], likely as a result of decreased renal blood flow, possible redistribution of intrarenal blood flow, and increased reabsorption of sodium chloride in the thick ascending loop of Henle. In elderly patients this increased sodium chloride reabsorption coupled with increased water reabsorption is more likely to result in the edema. 

In a similar study, Mamdani et al. conducted a retrospective cohort study from 1998- 2001 with NSAID naive elderly patients who had either celecoxib, ro-fecoxib, naproxen, or other non-naproxen NSAIDs. [155] Prior to adjusting compared to the community group there was a significant increased risk of AMIs for all NSAIDs except naproxen which only trended towards an increase. But once the values were adjusted for comparison to their controls none of the groups had an increased risk that was significantly different than the controls. This study was designed to determine if naproxen had would decrease the risk of AMIs and they concluded that naproxen has no cardioprotective properties. This study also showed an increased risk of AMI for high dose ibuprofen. 

No increased risk with celecoxib RR0.99 (0.85-1.16) compared to other NSAIDS. Increased risk for fatal and non-fatal Ml in elderly patients without a hx of Ml when using rofecoxib. No evidence of increased risk with other NSAIDs (including celecoxib). ... 

Mamdani etaLlU3] 2004 Population- Primary diagnosis based ofCHF retrospective cohort 38882 individuals 66 years and older who were prescribed study and 100000 randomly selected non-NSAID users matched by sex and age % study cohort w/ admission procedures for CHF in past 5 years Non-NSAID 4% (4475/100000). Celexocib 6% (1170/18908) Rofecoxib 6% (857/14583). Non-selective NSAIDS 5% (542/11606) Adjusted Rate Ratio Rofecoxib relative to celecoxib for admission for CHF 1.8 (1.4-2.4) Non-selective NSAIDs relative to celecoxib for admission for CHF 1.4 (1.0-1.9) and (rofecoxib users relative to non-NSAID users. Additional analysis with age-matched and sex-matched controls showed similar patterns. Increased risk of CHF in elderly patients when using rofecoxib and non-selective NSAIDs (but not celecoxib)... 

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