Management of Diverticular Disease

Introduction to Guideline Recommendations

The American Gastroenterological Association (AGA) recommends advising patients with a history of diverticulitis to avoid non-aspirin NSAIDs when possible 1
Patients with recurrent episodes or complicated diverticular disease should be especially careful to avoid non-aspirin NSAIDs 1

Acetaminophen should be the primary analgesic for pain management in patients with prior diverticular bleeding 2
For severe pain requiring stronger analgesia, opioids are preferable to NSAIDs in this population 2

Low-dose aspirin prescribed for secondary cardiovascular prevention should generally NOT be discontinued in patients with prior diverticular bleeding 1
The protective effects of aspirin on all-cause mortality and myocardial infarction typically outweigh the modest increased bleeding risk 1

Proton pump inhibitors (PPIs) reduce upper GI bleeding risk but do NOT protect against lower GI bleeding from diverticulosis 3
Co-prescribing a PPI does NOT make NSAID use safe in patients with prior diverticular bleeding 3

Educate patients about all NSAID-containing products, including combination cold/flu medications and topical preparations that may have systemic absorption 3
Provide written instructions listing specific medications to avoid by both brand and generic names 1

Do not assume that COX-2 selective inhibitors (coxibs) are safe alternatives - while they reduce upper GI risk, the evidence for lower GI protection is limited and they still carry cardiovascular risks 4
Do not rely on "GI-protective" formulations like enteric-coated or buffered NSAIDs - these do not significantly reduce lower GI bleeding risk 3
Do not forget to ask about over-the-counter NSAID use - many patients self-medicate with ibuprofen or naproxen without considering it "real medication" 3