Risks and Benefits of Nonsteroidal Anti-inflammatory Drugs in the Hemostatic System

Chronic use of multiple drugs increases risk of adverse drug reactions, drug interactions and poor therapeutic adherence. In elderly or frail patients, some drugs may become ineffective or even harmful with advancing age and worsening clinical conditions. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been extensively used for decades and, as a class, are both often inappropriately prescribed and involved in polypharmacotherapy untoward effects. In view of the dynamic and mutual relationship between inflammation and hemostasis in various clinical scenarios, use of anti-inflammatory agents, including NSAIDs, may tip this difficult balance in patients with hemostatic disorders. Rather than on well-established actions such as the clinically relevant antiplatelet action of low-dose aspirin and gastrointestinal bleeding, this review focuses on less highlighted, emerging or sometimes overlooked NSAID efficacy and safety endpoints. For instance, preclinical studies suggest that the antiplatelet action of low-dose aspirin enhances immune system activity against cancer cells, resulting in metastasis prevention. While use of NSAIDs in patients with coagulation disorders may have an acceptable risk-to-benefit ratio in selected patients, clinical judgement is required especially in cases of renal impairment that can be worsened by NSAIDs or in cases with high bleeding risk. In the context of polypharmacotherapy, attenuation of aspirin antiplatelet action by concomitant and inaccurately timed ibuprofen treatment may undermine the clinical benefit of aspirin in cardiovascular prevention. Thus, collaborative cross-disciplinary efforts of pharmacologists and clinicians would be desirable in order to enhance appropriateness, efficacy and safety of NSAID treatment in different settings of care.