A 58-year-old man with a 10-year history of osteoarthritis of both knees presents to the rheumatology clinic. He has been taking ibuprofen 400 mg three times daily for the past 6 months with good pain relief. On examination, his blood pressure is 148/92 mmHg (previously 130/80 mmHg 6 months ago). Serum creatinine has risen from 0.9 mg/dL to 1.3 mg/dL. Urinalysis shows mild proteinuria (1+). He denies any gastrointestinal symptoms. Which of the following is the most appropriate next step in management?

Question

Accepted Answer

B. Discontinue ibuprofen, switch to acetaminophen, and monitor renal function. ## Clinical Assessment

This patient demonstrates classic NSAID-induced renal injury with:
- Elevated blood pressure (new onset hypertension)
- Rising serum creatinine (0.9 → 1.3 mg/dL)
- Proteinuria on urinalysis
- Temporal relationship with NSAID use (6 months)

## Mechanism of NSAID Nephrotoxicity

**Key Point:** NSAIDs inhibit prostaglandin synthesis in the renal afferent arteriole, reducing glomerular filtration pressure. This is particularly dangerous in patients with:
  - Chronic kidney disease
  - Hypertension
  - Diabetes
  - Volume depletion
  - Advanced age

## Why Discontinuation Is Necessary

**High-Yield:** Once NSAID-induced renal injury is detected, the drug must be stopped. Unlike other adverse effects that may improve with dose reduction, NSAID nephrotoxicity is dose-independent and mechanism-based.

**Clinical Pearl:** Acetaminophen (paracetamol) is the safest alternative for chronic pain in patients with renal impairment, as it does not affect renal hemodynamics.

## Why Other Options Are Incorrect

| Option | Why Wrong |
|--------|----------|
| Amlodipine addition | Treats hypertension but does NOT address the underlying NSAID-induced renal injury; continuing the offending agent is inappropriate |
| Celecoxib switch | Selective COX-2 inhibitors carry similar renal risk as non-selective NSAIDs; they are NOT safer for renal protection |
| Dose reduction | NSAID nephrotoxicity is mechanism-based, not dose-dependent; reduction alone will not prevent further renal deterioration |

**Mnemonic:** **STOP NSAIDs** — *Serum creatinine Trending up, Proteinuria Observed, NSAIDs must be Stopped; Acetaminophen or other alternatives Indicated, Discontinue immediately, Safe renal monitoring*

[cite:KD Tripathi 8e Ch 12]

Answer

A. Continue ibuprofen and add amlodipine for blood pressure control

Answer

C. Continue ibuprofen but reduce the dose to 200 mg twice daily

Answer

D. Switch to a selective COX-2 inhibitor (celecoxib) for better renal safety

Explanation

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