Ibuprofen Contraindications and Precautions

Absolute Contraindications

The American Geriatrics Society recommends that ibuprofen is absolutely contraindicated in patients with active peptic ulcer disease, as NSAIDs cause serious gastrointestinal adverse events, including inflammation, bleeding, ulceration, and perforation of the stomach, small intestine, or large intestine, which can be fatal 1, 2
The American Academy of Family Physicians explicitly recommends avoiding NSAIDs in persons with renal disease due to risk of progressive renal deterioration leading to increased morbidity and mortality, and chronic kidney disease is an absolute contraindication to ibuprofen 3
Heart failure is an absolute contraindication (moderate level of evidence, weak recommendation), as NSAIDs cause sodium and water retention, worsening renal function and worsening heart failure 1, 2
Cirrhotic liver disease should be considered an absolute contraindication, as NSAIDs should not be used in persons with cirrhosis because bleeding problems and renal failure become more likely 4

The American Geriatrics Society recommends that a history of peptic ulcer disease (not currently active) represents a relative contraindication requiring extreme caution and gastroprotection, and patients with prior history of peptic ulcer disease and/or gastrointestinal bleeding who use NSAIDs have a greater than 10-fold increased risk for developing a GI bleed compared to patients without these risk factors 1, 2, 5
The American Academy of Family Physicians recommends avoiding NSAIDs in patients with hypertension, as NSAIDs can cause reduced sodium excretion leading to increased blood pressure (average increase of 5 mm Hg) 1, 2, 3
Impaired renal function, compromised fluid status, volume depletion, and elderly patients are at greatest risk of NSAID-induced renal decompensation, and concomitant use of diuretics, ACE inhibitors, or ARBs creates compounded nephrotoxicity risk and should be avoided or monitored extremely closely 3

The National Comprehensive Cancer Network recommends that NSAIDs taken with prescribed anticoagulants (warfarin or heparin) may significantly increase the risk of bleeding complications, particularly in patients at high risk for cardiac toxicities 6
Concomitant use with low-dose aspirin increases the risk of gastrointestinal bleeding and may reduce aspirin's cardioprotective efficacy 5
NSAIDs blunt the effects of diuretics, causing sodium and water retention and diuretic resistance, and combination with ACE inhibitors, ARBs, or diuretics creates a "perfect storm" where the kidney loses both vasodilatory and pressure-maintaining mechanisms, dramatically increasing nephrotoxicity risk 3

The American Geriatrics Society recommends that older persons taking nonselective NSAIDs should use a proton pump inhibitor or misoprostol for gastrointestinal protection, and well-tolerated proton pump inhibitors are recommended to reduce gastrointestinal adverse effects induced by NSAIDs 1, 2, 6, 5
All patients taking NSAIDs should be routinely assessed for gastrointestinal and renal toxicity, hypertension, heart failure, and other drug-drug and drug-disease interactions, and for high-risk patients on NSAIDs, weekly monitoring for the first three weeks is recommended by some experts, with immediate discontinuation if renal function doubles 1, 2, 3
Baseline serum creatinine measurement is recommended when starting NSAIDs in high-risk patients, and use the lowest effective dose for the shortest possible duration to minimize potential risk for adverse GI and renal events 3, 5