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A female patient, 53 years old, found “rheumatoid arthritis” for 14 years. She was treated with “painkiller” for a long time. She had chronic stomach and enteritis a few years ago and her diet has been bad. Recently, the body was extremely weak and struggling to walk. The family took her to the hospital for examination and found that serum creatinine was elevated and admitted to the hospital.

Further examination after admission, weighing only 44kg, body muscle atrophy.

Anemia, hemoglobin 84g / L, urine microprotein, hypokalemia, hypoproteinemia, serum creatinine 108 μmol / L (normal 45 ~ 84 μmol / L), kidney atrophy; gastroscope showed chronic gastritis, gastric mucosa thickening.

She is already suffering from chronic kidney failure. According to medical history and examination, the cause of her renal failure is drug-induced kidney injury, and the main cause of her kidney failure is her long-term “painkiller”.

 

I. Which medicines are the antipyretic analgesics?

Generally refers to the medical “non-steroidal anti-inflammatory drugs”, which have anti-inflammatory, antipyretic, analgesic effects, etc., because the chemical structure of these drugs does not have the glucocorticoid anthracycline, but also has antipyretic , analgesic, anti-inflammatory and other effects, it is called non-steroidal anti-inflammatory drugs.

1. The role and classification of non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs are a large family, divided into six according to their different chemical structures. We are familiar with aspirin, indomethacin, acetaminophen, dipyridamole, aminopyrine, phenylbutazone, Ibuprofen, futalin, meloxicam, celecoxib, rofecoxib, and nimesulide are all members of this family.

Although these drugs have a common role, the advantages of different types of drugs are also different, such as:

Low-dose aspirin is mainly used for anticoagulation and prevention of thrombosis.

Paracetamol (acetaminophen) has a significant cooling effect, but its anti-inflammatory and analgesic effects are relatively weak, so it is only used for fever and mild to moderate pain, such as headache caused by cold, joint pain, neuralgia and partiality. Headache, dysmenorrhea, etc. Almost all cold medicines (regardless of traditional Chinese medicine and western medicine) contain paracetamol.

Other kinds of drugs such as ibuprofen, fustatin, meloxicam, celecoxib, nimesulide, etc., have obvious analgesic effects, mainly used for acute gout attacks, rheumatism, rheumatoid and various arthritis, and tonicity. Spondylitis and some autoimmune diseases can relieve pain, treat stiffness and improve joint function.

2. Side effects of non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs have a wide range of effects, but there are many side effects, and some side effects are still very serious. More serious side effects are gastrointestinal side effects and kidney damage.

Gastrointestinal reaction: After administration, abdominal discomfort, stomach pain, pantothenic acid, nausea, vomiting, fullness, belching, loss of appetite and other dyspeptic symptoms may occur. A small number of patients may have stomach, duodenal ulcer or gastrointestinal bleeding after long-term use. Perforation, etc.

Therefore, it is recommended that patients take it after meals to minimize gastrointestinal irritation; avoid drinking alcohol; regular gastrointestinal risk assessment; if necessary, also take gastric mucosal protective agents such as azole drugs.

 

II. Kidney damage caused by non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs are currently the most common nephrotoxic drugs. The higher the dose, the longer the time of use and the higher the incidence.

Kidney damage caused by non-steroidal anti-inflammatory drugs is divided into acute kidney damage and chronic kidney damage.

Acute kidney damage

Prerenal acute renal failure:

Non-steroidal anti-inflammatory drugs can reduce blood flow in the kidney. It is prone to prerenal (ischemic) acute renal failure when taken in large quantities at one time. If the original renal atherosclerosis and renal blood supply are not good, patients are more likely to have it. occur. For example, elderly patients take a large amount of antipyretics, on the one hand, the drug causes insufficient blood supply to the kidney, on the other hand, when the fever is dehydrated, the blood volume is reduced, and the renal ischemia is aggravated, resulting in acute renal failure.

Prerenal acute renal failure is mainly characterized by a decrease in urine output (less than 700 ml of urine per day) and a mild to moderate increase in serum creatinine. Once found, it should be stopped in time, supplement blood volume, correct renal ischemia, and generally recover completely.

Acute allergic nephritis:

Like common drug allergies, it usually occurs within 1 day or several days after administration. The dosage is not large. Even when it is used once, it will react violently, showing oliguria (less than 400ml per day) or even no urine. At 150ml), serum creatinine increased rapidly; a small number of patients developed nephrotic syndrome, and the pathological manifestations were minor lesions. Some patients may be accompanied by systemic allergic reactions.

Once it appears, it should be discontinued immediately, and it can be treated with glucocorticoids. In severe cases, it can be treated with dialysis.

2. Chronic kidney damage

Long-term use of non-steroidal anti-inflammatory drugs can lead to chronic renal failure. Early kidney damage symptoms are not obvious, and individual patients may show an increase in nocturia, but they are often ignored. A small amount of proteinuria can occur in the medium-term damage. The urine protein is generally no more than 1 g/day, and mild microscopic hematuria and tubular urine can also occur.

Late renal tubular dysfunction is obvious, manifested by a significant increase in nocturia, low specific gravity urine, elevated serum creatinine, chronic renal failure, and renal atrophy. At the same time, complications of chronic renal failure such as renal hypertension, renal anemia, and calcium and phosphorus metabolic disorders have emerged.

Non-steroidal anti-inflammatory drugs lead to the treatment of chronic renal failure, but also timely withdrawal, low-salt low-fat high-quality protein diet, high-dose sartan or pulsin antihypertensive drugs to reduce blood pressure, reduce urine protein and delay kidney damage Glucocorticoid therapy can be used; at the same time, renal anemia and calcium and phosphorus metabolism disorders can be corrected.

 

III. No matter how good the drug is, don’t abuse it.

Since the first synthesis of aspirin in 1898, more than 100 kinds of non-steroidal anti-inflammatory drugs have been on the market. It is widely used in clinical anticoagulation, various fevers and relief of various pain symptoms. The treatment of various osteoarthritis and autoimmune diseases has made great contributions to medicine.

These drugs have anti-inflammatory, analgesic, antipyretic effects, and have a wide spectrum of action. They can be used in small pains and minor illnesses in life, and these drugs are mostly non-prescription drugs. They can be used at pharmacies without a doctor’s prescription. Buy, so it is one of the most widely used drugs.

According to statistics, about 30 million people use non-steroidal anti-inflammatory drugs every day in the world, which is one of the most widely used drugs in the world. At the same time as the relief of human suffering, the abuse phenomenon is also increasing, so its safety is also receiving more and more attention. Recently, the US Food and Drug Administration (FDA) believes that non-steroidal anti-inflammatory drugs have potential cardiovascular and gastrointestinal bleeding risks, requiring these drug manufacturers to provide warnings in their instructions.

In general, the benefits of non-steroidal anti-inflammatory drugs on humans outweigh the disadvantages, and the contribution is greater than the harm, and there is generally no problem in short-term use, so do not waste food because of many side effects. However, if you take these drugs for a long time, you must first make a clear diagnosis. If you should not use them, when should you use them, how much they should be used, how long they should be used, what should be paid attention to during medication, be sure to use them under the guidance of doctors, and strictly follow the doctor’s advice. Rational use of drugs.

In addition, the newly listed selective cyclooxygenase-2 (COX-2) inhibitors such as meloxicam, celecoxib, rofecoxib, nimesulide, etc., have good analgesic effects, digestive tract, kidney If the side effects are small, you should try to use them. (no cardiovascular disease)

This patient has no problem with rheumatoid arthritis and is treated with a non-steroidal anti-inflammatory drug. However, she has been taking chronic gastroenteritis and chronic renal failure for a long time. Because of chronic gastroenteritis, it also causes her malnutrition, anemia, low protein and so on.

Her serum creatinine 108 μmol/L does not seem to be too high, but her estimated glomerular filtration rate (eGFR) is 38.25 ml/min, and ECT is measured as GFR 42.43 ml/min, which belongs to CKD3b phase and is already moderately kidney. The decline is more serious.

We stopped her the original medication, using a low-salt diet, appropriate nutrition; sartan antihypertensive drugs to reduce urine protein, delay kidney damage; erythropoietin and iron to correct renal anemia; Calcium and ossification three Alcohol treatment of calcium and phosphorus metabolism disorders and other treatments.

There seems to be a contradiction in the treatment of her disease: no treatment with non-steroidal anti-inflammatory drugs, rheumatoid arthritis may recur, and return to the original pain, and even cause damage to other organs such as the kidney; continue to use This kind of treatment, kidney damage will be further aggravated.

The solution is that we give her a treatment with glucocorticoids. One is to continue to treat her rheumatoid arthritis, but it also has a therapeutic effect on chronic kidney damage caused by non-steroidal anti-inflammatory drugs.

Although glucocorticoids also have side effects of gastric mucosal damage, and even cause other side effects such as diabetes, the pros and cons are better than non-steroidal anti-inflammatory drugs for her. In fact, the author of acute gout with chronic renal failure, the preferred hormone rather than non-steroidal anti-inflammatory drugs, is also the reason.

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