Educating Steem: NSAIDs and Kidney Injury
Introduction
There is great importance in educating Steem about the dangers of taking over-the-counter medications. One thing is for sure—just because something does not require a prescription, does not make it safe! Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as ibuprofen are common medications that decrease inflammation by stopping prostaglandin synthesis. This can be a great way to decrease pain, inflammation, and reduce fever when used in moderation, but there are those who should not take them... and almost any person can be in a situation where it would be foolish to do so!
While many people know that NSAIDs like ibuprofen and naproxen can be hard on the stomach and cause ulcers, many common folk are not familiar with the danger to the kidneys! I will be discussing the mechanism of action on how NSAIDs can damage the kidney in multiple ways and give situations where any person could be in danger. Stomach issues and ulcers are another major problem with NSAIDs, but I will be sticking to the kidneys for this post!
Types of Acute Kidney Injury (AKI):
Acute kidney injury (AKI) is essentially a rapid decline in kidney function. This can be checked fairly easily by looking at the creatinine level in the blood. Creatinine is mostly removed by the kidney, so when the level is elevated, it means that the kidney cannot remove it well. We have many ways to figure out which type of damage occurs, but I will not bore you with those details in this article.
AKI is not uncommon, and I see it in many patients at the hospital. 577 out of 100,000 people will get AKI and LESS THAN HALF of these people had previous kidney disease (1). This is an important point because it does happens in people that had good function before the acute problem.
I also suspect that AKI is much more common than this because most kidney damage does not cause symptoms! You don’t “feel” kidney injury because it does not hurt. The only time one will will “feel” the effects of kidney damage is when one has no kidney function and needs dialysis. We find kidney injury because someone comes in with another problem. An older lady with pneumonia may also have AKI!
We categorize acute kidney problems into three general types: pre-renal, intrinsic, and post-renal. Pre-renal is damage to the kidney due to poor blood circulation. Intrinsic is when there is damage within the kidney itself; these two types are what can happen while taking NSAIDs. Post-renal is when damage occurs beyond the kidney. For example, a man with an enlarged prostate can have problems with urine clearance. This build up of urine can increase fluid around the kidney, increasing pressure, and causing damage.
I could dedicate multiple posts for each of these types (especially intrinsic), but to stick with the NSAID topic, let’s move on!
Mechanism of Action of NSAIDs
NSAIDs like Advil and Aleve work by inhibiting COX-1 and COX-2, which therefore, block prostaglandin synthesis. COX-2 inhibition leads to decreased inflammation, pain, and fever. These are the positive effects of taking NSAIDs. However, COX-1 and COX-2 both affect the kidney (2). This is important! Although COX-1 inhibition is believed to lead to ulcers in the stomach, both cause negative effects in the kidney. Therefore, drugs like Celebrex ( selective COX-2 inhibitors) while better on the stomach, will not lead to absolute renal protection.
Prostaglandins have a major benefit in the kidney. One major prostaglandin in the kidney is prostacyclin (2). Prostaglandins in the kidney cause vasodilation of the afferent tubule (WHAT is he talking about????).
Don’t panic!
To understand this, I will give a brief anatomy lesson. The kidney has an afferent tubule leading to the glomerulus (the main filtration structure of the kidney). When the blood moves past this filtration structure, it goes out the efferent tubule and exits. The kidney benefits by having more blood flow entering the glomerulus. Therefore, prostaglandins are beneficial to the kidney. When an NSAID is taken, these prostaglandins are synthesized less and there is more afferent vasoconstriction, leading to poorer blood flow to the glomerulus of the kidney.
A double-blinded study on 29 healthy subjects found that taking naproxen (Aleve) 500mg twice a day for 10 days had statistically significant reductions in kidney function compared to placebo (2). While these changes may have been transient, repeated attacks on the kidney can lead to permanent damage, "AKA" chronic kidney disease.
The problem mentioned above is a hemodynamic, pre-renal issue. It is simply lack of blood flow to the kidney, which can be caused by NSIAD use.
Another potential risk to the kidney while taking NSAIDs is acute interstitial nephritis (AIN). As of now, we are not certain why NSAIDs cause this, but it is believed to be immune mediated. One potential theory is that COX-inhibition leads to more leukotrienes, leading to more activation of white blood cells (specifically helper T-cells) (3).
It is also important to note that acute tubular necrosis (ATN) can occur with NSAIDs from ischemia (pre-renal disease turning into intrinsic disease). If there is not enough blood flow to the kidney, then intrinsic damage can occur from poor oxygenation to the renal tubules.
Who Should NOT take NSAIDs?
Now that the dangers are clear, who should be cautious?
Well, in my opinion, everyone should be cautious; however, many can still take NSAIDs safely. People who already have kidney disease should not take it. It puts the kidney in a vulnerable position, and someone with already poorer kidney function is not a good candidate. Beyond the kidney, people who get stomach ulcers should also avoid oral forms of NSAIDs.
This may seem easy to manage, but it is not. An older individual with arthritis and kidney disease makes decision making hard. For instance, this individual may be in pain but opiates and NSAIDs are not good options. Tylenol is not an NSAID, but is often not great at treating significant pain.
People without kidney disease should also be careful. For example, let’s say that a 52-year old who takes a diuretic ( like HCTZ) and Lisinopril (ACE-inhibitor) for high blood pressure also wants to take an over-the-counter NSAID for arthritis. This individual can take an Aleve but should exercise great caution! ACE-inhibitors are vasodilators of the efferent (opposite effect to the afferent tubule which also causes pooper perfusion). If this individual becomes dehydrated with the diuretic, then acute kidney injury could occur. I would advise this patient to be very well hydrated while taking the NSAID.
A Time When All Steemians Should Avoid NSAIDs
What other diuretics do we know of…..ALCOHOL.
Alcohol makes you “pee” a lot. Let’s say that a beautiful Steem woman goes out for a night of festivities. She becomes inebriated and returns home and passes out. Before she passes out, she decides to take a lot of NSAIDs to “prevent a hangover” in the morning. She wakes up the next day super-dehydrated. She drinks some water and feels better. She may have an acute kidney injury and never know it. It may resolve, and her kidneys may work fine after. However, with every AKI event, there is a chance of permanent kidney damage! Not a risk I would want to take. It makes you wonder if alcohol could be a cause of some idiopathic cases of chronic kidney disease. Just a thought. Diabetes and HTN are the main two leading to chronic kidney disease, but acute kidney injury can lead to permanent renal dysfunction.
Conclusion/Recommendations:
I hope this was an informative post for the Steem community. I still think NSAIDs can be very beneficial when used in the right context with the right people. It is also important to not “overuse” these drugs because they are not harmless. They can cause serious problems. My recommendation for a healthy Steemian is to take no more than is recommended on the package, avoid chronic use of them, and do not take them when dehydrated. If you are drinking alcohol, don’t even think about it! Those that have kidney disease, don’t take them.
If you have back pain and are healthy/hydrated go ahead and take them!
Just because you can buy something at a store, does not make it harmless! I highly doubt NSAIDs would have been approved by the FDA if they were made in this day and age.
Thank you for reading my important post on NSAIDs, and I hope everyone learned something new!!!
Stay tuned for more posts on medicine/science/music.
Hope everyone had a great weekend!!!!
Current senior medical student in my last 2 months of school!
Sources (cited within article as well):
1) http://emedicine.medscape.com/article/243492-overview#a6
2) http://www.medscape.org/viewarticle/422939_3
3) http://medsafe.govt.nz/profs/PUArticles/June2013NSAIDS.htm
***Edit) Source (2) link is not allowing access without an account. However, the article can be found by going to google and typing in....NSAIDs Cardio-Renal Physiology Medscape
All images from pixabay.com. Links provided under photos.
Really good to know! I take Tylenol a few times a week, and I think I'll ease up and drink a lot of water if I do take them. Thanks for the info!
Thanks for reading! I'm glad you wrote this because Tylenol is not an NSAID. It works centrally so it will reduce fever and pain but has no effect on the prostaglandins in the stomach or kidney. Tylenol at high doses can be dangerous to the liver but a far safer drug. You can keep taking your Tylenol!
Oh wow, thanks for that information, I'm so glad you let me know this!
Fantastic post @tfeldman. You broke down the science of why NSAIDS can be hazardous and explained that why in a very understandable manner. This is the kind of post people can really learn something from. Too often we are told oh this can be dangerous to the kidneys, but nobody really goes into the science so people are forced to take the statements at face value. Here people leave actually informed, having understood the why.
Thanks for reading as always! I appreciate that it was helpful. I stayed up pretty late last night putting this one together, and was very pleased at the reception this morning! I will try to write more posts centered on giving practical advice to the Steem community based on what I have learned/witnessed. Keep up the good work as usual!
Saving one kidney at a time!
Great article,
I am absolutely on your side, any oral medication needs to be processed in the liver!! unfortunately pills are always the first choice for a doctor to prescribe rater than giving you something that's provided by nature.
I believe in first do no harm kind of philosophy. The big point of this article is that these pills are often thought of as "weak". I would say they are very powerful. They are good drugs but need to be used with just as much caution as any prescription med.
The Steemit Doctor, Awesome! :P 2 more months to go! Congrats for making it through basically.
Thank you! Passed the big tests just a couple rotations for more experience! Glad you enjoyed the article.
Great article from the multi-talented @tfeldman. I took presription nsaids (Lodeine) for over 10 years, and definitely am paying the price. +1
Out of curiosity, what happened after 10 years of use? You don't have to answer that by any means if you don't want to.
Thank you for reading man! I am glad to help people. Hopefully this post saves a few kidneys in the long run!
Ulcers galore! To the point I can't eat hot sauce/peppers/etc......major lifestyle changes, as I've always loved spicy foods.
Also I've passed 40+ kidney stones, but that may or may not be related.
Rotten luck man! I don't know if the kidney stones were from the NSAID use although staying hydrated is a good advice for people that have them. I guess if you really want an NSAID you can inject it hah.
good, well structured informative blog @tfeldman, you used steemitclinic tag witch is awesome :)
i enjoyed it, upvoted and resteemed
by the way i am preparing a blog about Aspirin but not sure when it will be ready
Great. I will let you tackle the aspirin...You can read the reply to @pfunk for my take on it....I would be curious to see your take on it as well! It is for sure a good drug to prevent heart attack and stroke. To me it seems like the pros of that drug outweigh the cons....but in the right patient population of course.
Thanks for reading! Glad to help out the Steemitclinic. I hope more follow and contribute to it A great medical resource is forming!
great post dude!!
Appreciate it. Thank you for reading. Hope the info will help you in multiple situations.
cool post!
Thank you for reading. Good feedback and realizing that people benefited from the posts make it well worth it!
Nice post but there is a bit of a quirk in the system that when whales vote too much on one post, the rewards are blown up out disproportionately, staving out many other posts. I disagree that this is a positive for Steem. For that reason, I'm downvoting it but please don't take this as personal criticism or criticism of your post, it isn't that.
Yeah, I have remained pretty neutral on this issue. I will not lie it sucks to lose half of my earnings but you have the freedom to do that. I believe in freedom. My only critique would be on my last medical post on seizures I received 3 bucks. I believe that was worth more than that. So in a way I can see how sometimes a bigger payout makes up for not being noticed on another.
I hope you enjoyed the article and hopefully this awareness about NSAIDs will save lives. Look out for my posts when they are at 2 bucks haha.
As I have commented elsehwere, you should realize that a good part of the reason your received $3 is the rewards being hogged by a few top posts at the time. That is especially true at $3 (unlike those that are much lower) since it demonstrates that the post got a pretty good amount of voting, but reward fund was just too depleted to pay more.
Please keep posting, I like your medical posts and I would certainly vote them up in the future as long as it doesn't amount to extreme reward concentration.
I think your reasoning has good intentions as long as it is consistent. Hopefully when the price of Steem rises (and I believe it will) a payout of 40 bucks will be average.
I also think that people who keep most of their money in steem should also benefit from that. I play with some trading but use my Bitcoin money. Most of my posts for months have stayed within steem and I have never powered down. Distributing rewards can come at a price if those individuals take it out of the steem economy. While the work is more fairly distributed, the fate of steem hangs in the balance. Flooding the exchanges is part of the problem with low rewards too. Should a portion of my profit loss go to potential people who flood the market...I don't know. Just another thing to consider.
I respect that you gave me reasoning, and I hope from your actions.... either we come up with a better system to mitigate distribution without hurting a reputation or we find a way to distribute without you having to downvote. For instance, if you like my post you should be able to express that as a reputation increase at least.
Time usually solves differences in opinion. Complaining won't help. I believe in Steem and of course will keep posting. Positive comments drive me more than money.
Yes I certainly agree and that is why I am commenting at all on posts which make, say, $50. When the price of Steem hopefully rises and $50 is a "small" reward, I won't take note of it. A post that earns $50 now would probably earn over $2000 with the exact same voting back in July. It isn't the specific amount that matters, it is the nature of the voting and how it relates to the overall pool.
Thank you for your feedback.
Just because a few think they can drive on the wrong side of the road doesn't mean that's the way it should be.
I thought you should have kept that reward without anyone's opinion of your reward. You got it because whales decided to give you that. It's like you're saying it's okay to take your money and give it to someone more deserving, Who is 1 or a few people to say you are receiving too much.
I agree with some of your concern. Trust me, I didn't like losing 45 bucks. However, I was more frustrated with the negative effect on reputation. Yes my reputation went up but it lost just like the money. I think redistributing is a debatable topic in general but there should be a better way to go about it than in a negative looking way. Maybe changing the voting curve would resolve a lot of these issues.
Hi tfeldman, Question for Salazine EC ( 344 ) & Celebrex (7667 200mg)
thank you