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Preventing Chronic Disease | NSAID-Avoidance Education in Community Pharmacies for Patients at High Risk for Acute Kidney Injury, Upstate New York, 2011 - CDC


Preventing Chronic Disease | NSAID-Avoidance Education in Community Pharmacies for Patients at High Risk for Acute Kidney Injury, Upstate New York, 2011 - CDC

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NSAID-Avoidance Education in Community Pharmacies for Patients at High Risk for Acute Kidney Injury, Upstate New York, 2011

Soo Min Jang, PharmD; Jennifer Cerulli, PharmD; Darren W. Grabe, PharmD; Chester Fox, MD; Joseph A. Vassalotti, MD; Alexander J. Prokopienko, PharmD; Amy Barton Pai, PharmD

Suggested citation for this article: Jang SM, Cerulli J, Grabe DW, Fox C, Vassalotti JA, Prokopienko AJ, et al. NSAID-Avoidance Education in Community Pharmacies for Patients at High Risk for Acute Kidney Injury, Upstate New York, 2011. Prev Chronic Dis 2014;11:140298. DOI: http://dx.doi.org/10.5888/pcd11.140298External Web Site Icon.


Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently associated with community-acquired acute kidney injury (AKI), a strong risk factor for development and progression of chronic kidney disease. Using access to prescription medication profiles, pharmacists can identify patients at high risk for NSAID-induced AKI. The primary objective of this analysis was to evaluate the effectiveness of a community pharmacy–based patient education program on patient knowledge of NSAID-associated renal safety concerns.
Patients receiving prescription medications for hypertension or diabetes mellitus were invited to participate in an educational program on the risks of NSAID use. A patient knowledge questionnaire (PKQ) consisting of 5 questions scored from 1 to 5 was completed before and after the intervention. Information was collected on age, race, sex, and frequency of NSAID use.
A total of 152 participants (60% women) completed both the pre- and post-intervention questionnaire; average age was 54.6 (standard deviation [SD], 17.5). Mean pre-intervention PKQ score was 3.3 (SD, 1.4), and post-intervention score was 4.6 (SD, 0.9) (P = .002). Participants rated program usefulness (1 = not useful to 5 = extremely useful) as 4.2 (SD, 1.0). In addition, 48% reported current NSAID use and 67% reported that the program encouraged them to limit their use.
NSAID use was common among patients at high risk for AKI. A brief educational intervention in a community pharmacy improved patient knowledge on NSAID-associated risks. Pharmacists practicing in the community can partner with primary care providers in the medical home model to educate patients at risk for AKI.


More than 98 million nonsteroidal anti-inflammatory drug (NSAID) prescriptions were filled in 2012 (1). NSAIDs have accounted for more than 70 million prescriptions and 30 billion over-the-counter purchases (2). NSAIDs are also among the most common medications prescribed inappropriately to older Americans (1,3). Among a cohort of 12,065 participants in the cross-sectional National Health and Nutrition Examination Survey who had an estimated glomerular filtration rate (eGFR) between 15 and 50 mL/min/1.73m2, 5% reported using over-the-counter NSAIDs regularly and 66.1% had used these agents for 1 year or longer (4).
Frequent, unmonitored use of NSAIDs among high-risk patients is associated with the development of acute and chronic kidney injury (5). NSAID use is a common inciting factor for community-acquired acute kidney injury (AKI) (6). NSAID-induced AKI abruptly alters renal hemodynamics, lowering effective perfusion of the glomerulus (7,8).
Interruption of this regulatory pathway increases the risk for hemodynamically mediated AKI, especially in patients who depend on vasodilatory prostaglandins to maintain kidney perfusion (7,8). Concomitant use of antihypertensive drugs and NSAIDs has been associated with a 5-fold increase in AKI risk (9). The relative risk for AKI among concurrent users of NSAIDs and diuretics is 3-fold higher than the risk among nonconcurrent users, likely because of decreased intravascular volume and renal perfusion (9). Angiotensin-converting enzyme inhibitors (ACEIs) dilate efferent arterioles and reduce glomerular capillary pressure, inhibiting the ability of the efferent arteriole to constrict when the renin–angiotensin–aldosterone system is activated or afferent arteriole vasodilatation is insufficient (7,10). Both current and recent use of ACEIs has been associated with as much as a 3-fold increase in the risk for AKI (9). Differences in pharmacologic selectivity and potential to cause intrarenal hemodynamic changes exist among NSAIDs; however, NSAID-induced AKI depends also on patient factors, which limits the ability to predict outcomes according to each NSAID (11,12).
The implications of an episode of AKI are relevant to chronic kidney disease (CKD). After an episode of AKI, kidney function is presumed to be fully recovered if serum creatinine levels return to baseline. However, recent data showed that up to 70% of elderly patients were predisposed to progression and development of de novo CKD within 2 years of an episode of AKI (13,14). NSAIDs are an important contributor to risk for AKI and a more rapid progression of CKD. In a cohort analysis of more than 10,000 patients aged 66 years or older, a high dose of NSAIDs was associated with a 26% increase in the risk for a decline in eGFR of more than 15 mL/min/1.73 m2 within 2 years (15).
This increased risk for adverse kidney events related to NSAIDs prompted the National Kidney Foundation to recommend displaying a clear warning on over-the-counter NSAID labels in 1985 (16). The NSAID Patient Safety Study collected data on NSAID use in primary care practices in Alabama (17). Patients who were identified as current NSAID users were contacted by telephone to participate in a survey. Among the survey participants, 63% used both over-the-counter and prescription NSAIDs, and only 13.7% patients recalled discussing NSAID use with a pharmacist. The authors concluded that pharmacists and pharmacy staff are missing an opportunity to provide counseling to high-risk patients to avoid inappropriate and unsafe NSAID use. The patient surveys indicated that a community pharmacy intervention could be valuable in increasing awareness of the risks of NSAID-induced AKI.
Provision of NSAID avoidance education to patients at risk for AKI is an important but underappreciated prevention strategy. Community pharmacists are readily accessible to these high-risk patients as they visit the pharmacy for prescription refills and over-the-counter purchases (18,19). The primary objective of this pilot project was to design and evaluate the effectiveness of a community pharmacy–based patient education program to increase awareness of the safety issues associated with NSAID use among patients at high risk for AKI. The primary outcome measure was patient knowledge questionnaire (PKQ) scores before and after the intervention. Secondary objectives were to quantify current use of NSAIDs and to determine whether the intervention encouraged patients to reduce their NSAID use.


The educational intervention and surveys were conducted at multiple Albany College of Pharmacy and Health Sciences (ACPHS) Community Pharmacy Advanced Pharmacy Practice Experience (CPAPPE) sites. We thank the preceptors and students for their participation. There was no financial support for the work.

Author Information

Corresponding Author: Amy Barton Pai, PharmD, BCPS, Albany College of Pharmacy and Health Sciences, 106 New Scotland Ave, Albany, NY 12208. Telephone: 518-694-7203. E-mail: amy.bartonpai@acphs.edu.
Author Affiliations: Soo Min Jang, Darren Grabe, Albany College of Pharmacy and Health Sciences, Albany, New York, and ANephRx Albany Nephrology Pharmacy Group, Albany, New York; Jennifer Cerulli, Alexander J. Prokopienko, Albany College of Pharmacy and Health Sciences, Albany, New York; Chester Fox, University of Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York; Joseph A. Vassalotti, Icahn School of Medicine at Mount Sinai, New York, New York. Soo Min Jan, Darren Grabe, Chester Fox, and Joseph Vassalotti are also members of the New York State Chronic Kidney Disease Coalition, Albany, New York.


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