Which patients should not use NSAIDs? A vital guide to safety

October 12, 2025 •

5 min read

According to the National Institutes of Health, NSAID-related upper gastrointestinal adverse events lead to tens of thousands of hospitalizations annually in the United States alone. For this reason, knowing which patients should not use NSAIDs is critically important to prevent serious complications.

Quick Summary

Individuals with heart disease, kidney dysfunction, or a history of stomach bleeding face increased risks with NSAID use and should avoid these medications. Pregnant women and older adults also have higher risks for adverse events.

Key Points

Heart and Cardiovascular Disease: Patients with a history of heart attack, heart failure, or uncontrolled high blood pressure should be extremely cautious or avoid most NSAIDs.
Kidney Dysfunction: Those with chronic kidney disease or existing renal problems face a heightened risk of acute kidney injury from NSAID use.
Gastrointestinal History: Individuals with stomach ulcers, a history of GI bleeding, or inflammatory bowel disease should not take NSAIDs due to severe bleeding risks.
Pregnancy and Age: The FDA recommends avoiding NSAIDs from 20 weeks of pregnancy onward, and older adults over 65 have a significantly higher risk of adverse effects.
Drug Interactions: Combining NSAIDs with blood thinners, certain blood pressure medications (ACE inhibitors, diuretics), or corticosteroids can drastically increase bleeding and kidney complication risks.
Alternatives Exist: For those who cannot use NSAIDs, alternative pain relief options like acetaminophen, topical creams, and physical therapies are safer choices.

Who Should Avoid NSAID Use?

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin), naproxen (Aleve), and celecoxib (Celebrex) are widely used for pain, fever, and inflammation. However, they are not safe for everyone and carry significant risks for certain patient populations. Understanding these contraindications is essential for responsible pain management.

Cardiovascular Disease and High Blood Pressure

For individuals with heart and cardiovascular problems, NSAID use carries a heightened risk of complications. All NSAIDs, except low-dose aspirin used under medical supervision, can increase the risk of heart attack and stroke. This risk is particularly high for those with pre-existing conditions and increases with higher doses or prolonged use.

Heart Failure: In patients with pre-existing congestive heart failure, NSAIDs can worsen the condition. This is due to their ability to cause sodium and fluid retention, which increases the volume of blood the heart has to pump. NSAIDs should be avoided by patients with severe heart failure.
High Blood Pressure (Hypertension): Many NSAIDs can raise blood pressure and reduce the effectiveness of common blood pressure medications like ACE inhibitors and diuretics. Patients with uncontrolled hypertension should consult their doctor before using NSAIDs.
Recent Heart Attack or CABG Surgery: Using NSAIDs shortly after a heart attack can increase the risk of recurrent cardiovascular events and serious bleeding. These drugs are also contraindicated following coronary artery bypass graft (CABG) surgery.

Kidney Dysfunction

NSAIDs are primarily removed from the body by the kidneys. The mechanism by which NSAIDs cause kidney problems involves the inhibition of prostaglandins, which are important for maintaining blood flow to the kidneys, especially in times of stress. This can lead to decreased blood flow and reduced kidney function.

Chronic Kidney Disease (CKD): For patients with moderate to advanced kidney disease, NSAIDs should generally be avoided. Using them can lead to acute kidney injury, a sudden and potentially reversible decline in kidney function, but in some cases, the damage may be permanent.
Dehydration: Taking NSAIDs while dehydrated significantly increases the risk of kidney damage.
Drug Combinations: The risk is compounded when NSAIDs are taken with other drugs that affect kidney function, such as diuretics.

Gastrointestinal Problems

NSAID use can irritate the gastrointestinal (GI) tract and carries a well-documented risk of causing ulcers and bleeding. This happens because NSAIDs inhibit cyclooxygenase-1 (COX-1), an enzyme that helps produce prostaglandins, which protect the stomach lining.

Stomach Ulcers or Bleeding History: The risk of developing or re-experiencing a peptic ulcer or GI bleed is significantly higher for individuals with a history of these issues. NSAIDs can make these existing conditions much worse.
Inflammatory Bowel Disease (IBD): Patients with ulcerative colitis or Crohn’s disease should avoid NSAIDs, as they can exacerbate symptoms and trigger flare-ups.
Concomitant Medications: The risk of GI bleeding increases dramatically when NSAIDs are combined with other medications that increase bleeding risk, such as anticoagulants (blood thinners) and corticosteroids.

Pregnancy and Older Adults

Certain life stages and demographics require special caution regarding NSAID use.

Pregnancy: The U.S. Food and Drug Administration (FDA) recommends avoiding NSAIDs from 20 weeks gestation onward. Using them during this time can cause serious fetal kidney problems leading to low levels of amniotic fluid, which can result in severe complications. Late-stage use also carries risks for the baby's heart. Low-dose aspirin is sometimes used for specific conditions under a doctor's care.
Adults Over 65: Older adults are more susceptible to serious side effects from NSAIDs, including GI bleeding, kidney damage, and cardiovascular problems. The lowest effective dose for the shortest duration is recommended, if NSAIDs must be used.

Allergies and Other Conditions

Allergy to NSAIDs: Individuals with a known hypersensitivity or allergic reaction to aspirin or other NSAIDs (which can cause asthma or urticaria) should not use them.
Asthma: Certain individuals with asthma, particularly those with nasal polyps or chronic sinusitis, may experience an exacerbation of symptoms (aspirin-exacerbated respiratory disease) when taking NSAIDs.
Diabetes: NSAID use in patients with type 2 diabetes has been associated with an increased risk of heart failure, especially in older adults.

NSAID Alternatives for Safer Pain Management

For those who cannot use NSAIDs, several effective alternatives exist:

Acetaminophen (Tylenol): A common and generally safe option for pain and fever, but it does not treat inflammation. Patients with liver disease should be cautious and adhere to dosage limits.
Topical Pain Relievers: These products, like menthol or capsaicin creams, are applied directly to the skin and have minimal systemic absorption, reducing the risk of widespread side effects.
Non-Drug Therapies: Options like physical therapy, ice, heat, massage, and acupuncture can provide relief for musculoskeletal pain.
Other Medications: For inflammatory conditions, a doctor might prescribe corticosteroids, and for severe pain, opioids might be considered under strict medical supervision.

Comparison of NSAID Risks


Risk Factor	Non-selective NSAIDs (e.g., Ibuprofen, Naproxen)	COX-2 Selective NSAIDs (e.g., Celecoxib)
Gastrointestinal Bleeding	Higher risk, particularly with higher doses and longer duration. Inhibits COX-1, which protects the stomach lining.	Lower risk of upper GI bleeding, but risk is still present. Some studies suggest Celecoxib is relatively safer for the GI tract.
Cardiovascular Events	Increased risk of heart attack and stroke, especially with higher doses and chronic use.	Some agents (like rofecoxib, now withdrawn) have been linked to higher CV risk. Celecoxib has a more balanced profile but still carries a warning.
Kidney Effects	All NSAIDs can cause kidney injury by reducing blood flow, especially in patients with pre-existing kidney disease or dehydration.	Also poses a risk for kidney function due to effects on renal prostaglandins.
Overall Risk Profile	Higher GI risk, generally considered more balanced for CV risk than high-risk COX-2 inhibitors.	Lower GI risk, but variable CV risk profile; celecoxib risk profile differs from others in its class.

Conclusion

While NSAIDs are highly effective medications for a range of conditions, their use is not universally safe. A number of pre-existing health conditions, age, and pregnancy status can significantly increase the risk of severe adverse effects, from gastrointestinal bleeding and kidney damage to cardiovascular events. It is crucial for patients to be aware of their individual risk factors and to always consult with a healthcare professional before taking an NSAID, whether it is over-the-counter or prescription strength. For those who must avoid NSAIDs, safer alternatives and non-pharmacological therapies can often provide effective relief. The key to safe pain and inflammation management is informed decision-making in consultation with a doctor.

Based on information from the FDA Drug Safety Communication regarding pregnancy and NSAIDs, it is clear that patient-specific factors are paramount in evaluating risk.

Frequently Asked Questions

If you have high blood pressure, you should talk to a healthcare professional before taking an NSAID. Many NSAIDs can raise blood pressure and interfere with antihypertensive medications like ACE inhibitors and diuretics.

The FDA recommends that pregnant women avoid NSAIDs starting at 20 weeks gestation or later, as these medications can cause kidney problems in the unborn baby. Safer alternatives like acetaminophen are often recommended.

Yes, safer options exist. Acetaminophen is generally recommended as an alternative for pain and fever for those with kidney disease. Topical NSAID gels or creams can also be an option for localized pain, as they have lower systemic absorption.

Combining NSAIDs with blood thinners (anticoagulants) significantly increases the risk of serious bleeding, including gastrointestinal hemorrhage. This combination should generally be avoided unless your doctor has specifically instructed otherwise.

Yes, adults over 65 have a greater risk for serious side effects from NSAIDs, including gastrointestinal bleeding, kidney damage, and heart problems. If NSAIDs are necessary, a doctor will recommend the lowest possible dose for the shortest duration.

If you have a history of stomach ulcers or gastrointestinal bleeding, you should not take NSAIDs. These medications can re-aggravate the condition and increase the risk of a new bleed. Always consult your doctor for alternative treatment options.

Immediate medical attention is needed if you experience swollen ankles, difficulty breathing, chest pain, black stools, or vomit that looks like coffee grounds. These can be signs of heart problems, kidney issues, or gastrointestinal bleeding.