Nephrologists! Sulindac use in Alport's syndrome?

[Qadgop_the_Mercotan]

My pet nephrologist is off for the weekend, and I haven’t found a good answer on the net yet. Is there any consensus on whether it’s safe to use sulindac regularly for 2 or 3 weeks if the patient has Alport’s syndrome?

And please don’t post links to sites which say “sulindac should be avoided or used cautiously in patients with renal disease”. I know that. I would like to hear thoughts on whether sulindac is really less nephrotoxic in such a setting than other NSAIDs, and if so, whether a case could be made for its use.

Thanks, gang!
QtM

[Duck_Duck_Goose]

… … So, lemme see now, Q the M is asking for medical advice in General Questions, and he wants the Teeming Millions to tell him–the Professional Doctor Person, who went to medical school and everything, and who is usually one of the first posters to tell people who ask relatively minor questions like [sub]“what is this rash?”[/sub] or [sub]“why does my arm hurt?”[/sub], “We can’t give medical advice over the Internet, for legal reasons, so see a physician”–so this actual professional doctor wants us to advise him as to whether it’s okay to prescribe Sulindac for a few weeks for one of his patients who has Alport’s.

Geez. [insert emoticon for extreme bafflement]
Okay, troll, what have you done with the real Q the M?

geez, Q, how the hell are WE supposed to know?

please don’t post links to sites which say “sulindac should be avoided or used cautiously in patients with renal disease”.

As you already evidently discovered, that’s about all that’s out there. Google, “sulindac nephrotoxic alport’s” brings up no results. Google, “sulindac alport’s” and “sulindac alport”, nothing useful.

Google, “sulindac less nephrotoxic other NSAIDs”, sulindac seems to be less nephrotoxic than others, but I don’t see any definite “yes” or “no” answers offhand.

RxList Page Not Found

Renal Effects

As with other non-steroidal anti-inflammatory drugs long term administration of sulindac to animals has resulted in renal papillary necrosis and other abnormal renal pathology. In humans, there have been reports of acute interstitial nephritis with hematuria, proteinuria, and occasionally nephrotic syndrome.

A second form of renal toxicity has been seen in patients with prerenal and renal conditions leading to a reduction in renal blood wflow or blood volume where the renal prostaglandins have a supportive role in the maintenance of renal perfusion. In these patients administration of an NSAID may cause a dose dependent reduction in prostaglandin formation and may precipitate overt renal decompensation. Sulindac may affect renal function less than other NSAIDs in patients with chronic glomerular renal disease (see CLINICAL PHARMACOLOGY). Until these observations are better understood and clarified, however, and because renal adverse experiences have been reported with sulindac (see ADVERSE REACTIONS) caution should be exercised when administering the drug to patients with conditions associated with increased risk of the effects of non-steroidal anti-inflammatory drugs on renal function, such as those with renal or hepatic dysfunction, diabetes mellitus, advanced age, extracellular volume depletion from any cause, congestive heart failure, septicemia, pyelonephritis, or concomitant use of any nephrotoxic drug. Discontinuation of NSAID therapy is typically followed by recovery to the pretreatment state.

Since sulindac is eliminated primarily by the kidneys, patients with significantly impaired renal function should be closely monitored; a lower daily dosage should be anticipated to avoid excessive drug accumulation.

Sulindac metabolites have been reported rarely as the major or a minor component in renal stones in association with other calculus components. Sulindac should be used with caution in patients with a history of renal lithiasis, and they should be kept well hydrated while receiving sulindac.

http://collection.nlc-bnc.ca/100/201/300/cdn_medical_association/cmaj/vol-155/0077.htm

Similarly, the pro-drug, sulindac, has been reported to cause less renal insufficiency in patients with very mild pre-existing renal disease, but this remains controversial.[79,80]

http://www.pharmnet.co.za/druginfo/therapies/p_workshop_nsaids.htm

In terms of other side effects, indomethacin and fenoprofen appear to have more significant antiplatelet activity and may therefore be more likely to produce bleeding tendencies. Sulindac appears to be the least nephrotoxic whereas tiaprofenic acid may have a higher risk for the occurrence of cystitis and other adverse renal reactions. Piroxicam has been reported to cause a higher incidence of gastric side effects in the elderly while indomethacin may be more likely to cause confusion and CNS effects in this patient population.

best I can do, sorry
you want a definite “yes” or “no” answer, you should know better than to ask on an Internet message board

I mean, geez, Q…

[Achernar]

Next up, Duck Duck Goose asks how to locate things on the internet. “I’m just no good with search engines,” she says.

[astro]

It’s only contra indicated to the extent any NSAID is in the treatment of patients with Alports, which is to say it’s not singled out as being any more or less toxic than other NSAID drugs in this context.

If you are looking for reduced NSAID complications keep the level low at 150 mg and make sure the patient is taking asprin along with the Sulindac which will boost the NSAID effect without increasing potenital toxicity risks for patients with compromised renal scenarios.

[Qadgop_the_Mercotan]

Just lookin’ for info, DDG :D. Not quite the same as advice. I will be the one to prescribe or not prescribe the drug in the end, and on my head will ride the liability.

I also know there are quite a few people here that can do a scientific search better than I, plus a lot of much more scientifically-minded medical types, like KarlGauss, among others.

Basically I was hoping someone like that could lead me to the promised land of useful information to base my decision on. But I can certainly wait until my local nephrologist is back on Monday.

I was also wondering if sulindac really had lived up to its initial hype of being less nephrotoxic than other NSAIDs. Theory is fine, but I’ve never seen any actual clinical studies about its renal effects vs. other meds.

[KarlGauss]

I should be so lucky. But there isn’t a chance that I could ever come up with something that Qadgop didn’t already know.

Do all the fine people of the SDMB realize just how well informed and how utterly rational QtM is? I for one am continually awed by the breadth and depth of his knowledge.

Of course, none of this stopped me from trying a PubMed search on the question. The striking result is the absence of striking results. There is almost no recent data and what there is involves small numbers of subjects with what I suspect are suspect experimental designs. Example 1. Example 2. (These ‘results’ are pretty much what I expected since, just like you Qad, I remember the hope/hype that sulindac would be less nephrotoxic than other NSAID’s but have been waiting for proof/confirmation ever since. In fact, it’s been so long in not coming that I had almost forgotten the notion until you reminded me with this thread. Thanks!)

[Irony]
Just today, we were discussing what the most nephrotoxic NSAID would be. We were considering using it in a patient who presented with Bartter’s Syndrome (actually, it may be Gitelman’s). I kept getting mixed up with which NSAID is the most GI-toxic (IMO that honour would go to piroxicam a.k.a. Feldene)
[/irony]

[Qadgop_the_Mercotan]

Thanks for digging for me, KarlGauss. Too bad neither of us found paydirt.

IMHO, clinically I found my patients had the most complaints on indomethacin re: GI distress. Decidedly unscientific, this assumption by anecdote; but there you have it.

BTW, Steve. Got any cutting-edge info on cystic fibrosis-related diabetes? I haven’t seen much new on it since the general articles of the mid 90’s by Moran and others.

QtM

[Qadgop_the_Mercotan]

*Originally posted by KarlGauss *
** Do all the fine people of the SDMB realize just how well informed and how utterly rational QtM is? **

Boy, my true personality really, really doesn’t come across very well online, does it?

Seriously, I’m more a jack of all trades in medicine, but the deep knowledge is very hit or miss.

Thanks for thinkin’ of me!