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Should Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) be Prescribed to the Older Adult?

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Abstract

The prevalence of chronic pain increases with age, exceeding 50% in individuals aged ≥65 years. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a mainstay of chronic pain management but carry significant dose-related risks of cardiovascular, renal, haematological and other systemic adverse events (AEs). Older patients have an increased risk of these AEs and are more likely to take multiple medications that can potentially interact with NSAIDs. In particular, older patients are more likely to have cardiovascular disease and a natural age-related decline in renal function, increasing the risks of cardiovascular, haematological and renal AEs. Given these risks, recent guidelines for the management of chronic pain in the elderly recommend using NSAIDs rarely and only in carefully selected patients. NSAIDs currently available in the US fall into three categories: nonselective NSAIDs that act via inhibition of cyclo-oxygenase (COX)-1 and COX-2; celecoxib, a selective inhibitor of COX-2; and topical NSAIDs that inhibit both COX-1 and COX-2 but result in much less systemic NSAID exposure than oral formulations. Topical NSAIDs have demonstrated efficacy similar to oral NSAIDs, with an incidence of AEs similar to placebo; however, these agents are an option only in patients with localized pain in superficial joints. Safe pain management in older patients therefore requires cautious choice of selective and nonselective oral NSAIDs, topical NSAIDs or non-NSAID analgesics. This article discusses the risks and benefits of NSAID therapy, reviews its mechanism of action as the source of adverse effects and provides recommendations for maximizing NSAID safety, particularly in older patients. Articles cited in this review were identified via a search of PubMed (January 2005 to November 2009) and a manual search of reference lists from the articles identified in that search. Priority was given to articles discussing NSAID use in older populations, clinical trials of high quality, reports on NSAID safety and AEs, and treatment guidelines.

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Acknowledgements

Jeffrey Coleman, MA, and Robert Gatley, MD, of Complete Healthcare Communications, Inc. (Chadds Ford, PA, USA) provided editorial support for this article (literature search, document retrieval, medical writing and copy editing), with funding from Endo Pharmaceuticals Inc., Chadds Ford, PA, USA. Endo Pharmaceuticals made no contribution to the content of this article. None of the authors had any direct or indirect commercial financial incentive associated with publishing the article. The authors have no conflicts of interest that are directly relevant to the content of this review.

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  1. Departments of Anesthesiology, Family Medicine and Pharmacology, Rush University Medical Center, Chicago, Illinois, USA

    Robert L. Barkin

  2. Department of Anesthesiology, North Shore University Health System Pain Centers Skokie and Evanston Hospital, Skokie, Illinois, USA

    Robert L. Barkin

  3. North Shore University Health System Pain Center, Skokie Hospital, Skokie, Illinois, USA

    Mihail Beckerman, Steven L. Blum & Dickson S. Wu

  4. North Shore University Health System Pain Center, Evanston Hospital, Evanston, Illinois, USA

    Frank M. Clark & Eun-Kyu Koh

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Barkin, R.L., Beckerman, M., Blum, S.L. et al. Should Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) be Prescribed to the Older Adult?. Drugs Aging 27, 775–789 (2010). https://doi.org/10.2165/11539430-000000000-00000

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