Contraindications and High-Risk Situations for Diclofenac

Absolute Contraindications

• The American Heart Association recommends that diclofenac is absolutely contraindicated in patients undergoing coronary artery bypass graft (CABG) surgery, due to increased risk of cardiovascular thrombotic events 1, 2

High-Risk Cardiovascular Situations

• The American College of Cardiology recommends that diclofenac should be avoided in patients with cardiovascular disease or risk factors, as it increases vascular events by 63% (RR 1.63) compared to placebo 1, 2
• The American Heart Association recommends that diclofenac should be avoided in patients with history of myocardial infarction, where it increases recurrent MI risk by 54% (RR 1.54) and mortality by 140% (RR 2.40) 1, 2

High-Risk Gastrointestinal Situations

• The American Gastroenterological Association recommends that diclofenac should be avoided in patients with history of NSAID-associated upper GI bleeding, as risk of bleeding recurrence is 5% in first 6 months 3
• The American College of Gastroenterology recommends that if diclofenac must be used in patients with prior complicated upper GI ulcer, use COX-2 selective inhibitor plus proton pump inhibitor if GI bleed occurred within past year 5

High-Risk Hepatic Situations

• The American Association for the Study of Liver Diseases recommends that diclofenac should be avoided in patients with cirrhosis, due to potential for hematologic and renal complications 3
• The American Liver Foundation recommends that diclofenac should be avoided in patients with hepatic dysfunction or active hepatitis, as it shows higher rates of hepatic injury and transaminase elevation (>3× upper limit of normal) compared to other NSAIDs 4, 6

High-Risk Renal Situations

• The National Kidney Foundation recommends that diclofenac should be avoided in patients with chronic kidney disease stage IV or V (eGFR <30 mL/min), as oral NSAIDs should not be used 5, 7
• The American Society of Nephrology recommends that diclofenac should be avoided in patients with preexisting renal disease, as NSAIDs can cause volume-dependent renal failure 4

Hematologic Contraindications

• The American Society of Hematology recommends that diclofenac should be avoided in patients with platelet defects or thrombocytopenia, due to antiplatelet effects 3, 4

Special Population Considerations

• The American Geriatrics Society recommends that in elderly patients (≥75 years), strongly recommend topical rather than oral NSAIDs if NSAID therapy is necessary 5
• The American College of Cardiology recommends that in patients requiring low-dose aspirin for cardioprotection, do NOT use ibuprofen due to pharmacodynamic interaction that renders aspirin less effective 5

Common Clinical Pitfalls to Avoid

• The American Heart Association recommends that naproxen has more favorable cardiovascular safety profile and should be used instead of diclofenac as first-line NSAID in cardiovascular disease 9, 6
• The National Kidney Foundation recommends that diclofenac should not be combined with other nephrotoxic drugs without close monitoring 3, 4