Can diclofenac be given to a patient with Chronic Kidney Disease (CKD)?

From the Guidelines

Diclofenac should be avoided in patients with chronic kidney disease (CKD) due to the risk of worsening kidney function and other complications. As a nonsteroidal anti-inflammatory drug (NSAID), diclofenac can reduce renal blood flow through inhibition of prostaglandin synthesis, leading to acute kidney injury, further progression of CKD, fluid retention, and worsening hypertension 1. The American College of Rheumatology recommends that oral NSAIDs should not be used in patients with chronic kidney disease stage IV or V (estimated glomerular filtration rate below 30 cc/minute), and the decision to use an oral NSAID in patients with chronic kidney disease stage III (estimated glomerular filtration rate between 30 and 59 cc/minute) should be made on an individual basis after consideration of the benefits and risks 1.

Some key points to consider when managing pain in CKD patients include:

• Using safer alternatives such as acetaminophen (paracetamol) for mild to moderate pain, or tramadol or low-dose opioids for more severe pain under close medical supervision
• Monitoring kidney function, blood pressure, and electrolytes closely if an NSAID is used
• Being aware of potential drug interactions, as CKD patients often take multiple medications that may interact with diclofenac
• Avoiding the use of NSAIDs in patients with advanced stages of CKD (stages 3-5) due to increased risk of complications.

Overall, the potential risks associated with diclofenac use in CKD patients outweigh the benefits, and alternative pain management strategies should be prioritized to minimize harm and optimize patient outcomes.

From the FDA Drug Label

Renal Toxicity and Hyperkalemia Renal Toxicity Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. Renal toxicity has also been seen in patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion In these patients, administration of an NSAID may cause a dose-dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decompensation Patients at greatest risk of this reaction are those with impaired renal function, dehydration, hypovolemia, heart failure, liver dysfunction, those taking diuretics and ACE inhibitors or ARBs, and the elderly. Discontinuation of NSAID therapy is usually followed by recovery to the pretreatment state No information is available from controlled clinical studies regarding the use of diclofenac potassium tablets patients with advanced renal disease. The renal effects of diclofenac potassium tablets may hasten the progression of renal dysfunction in patients with preexisting renal disease. Correct volume status in dehydrated or hypovolemic patients prior to initiating diclofenac potassium tablets Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia during use of diclofenac potassium tablets (see PRECAUTIONS: Drug Interactions). Avoid the use of diclofenac potassium tablets in patients with advanced renal disease unless the benefits are expected to outweigh the risk of worsening renal function If diclofenac potassium tablets are used in patients with advanced renal disease, monitor patients for signs of worsening renal function.

Use of diclofenac in CKD patients should be done with caution. The drug label warns that renal toxicity and hyperkalemia can occur, especially in patients with impaired renal function. It is recommended to:

• Correct volume status in dehydrated or hypovolemic patients before initiating diclofenac
• Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia during use of diclofenac
• Avoid use in patients with advanced renal disease unless the benefits outweigh the risk of worsening renal function
• Monitor patients for signs of worsening renal function if diclofenac is used in patients with advanced renal disease 2 2

From the Research

Diclofenac Use in CKD Patients

• Diclofenac may be well tolerated in patients with chronic kidney disease (CKD) when used at the lowest effective dose for the shortest duration 3.
• The use of nonsteroidal anti-inflammatory drugs (NSAIDs), including diclofenac, in CKD patients is challenging due to the risk of nephrotoxicity and altered drug metabolism and excretion 4.
• Diclofenac has a shorter half-life and high efficacy, which may make it a suitable alternative for pain management in CKD patients 3.
• The risk of acute interstitial nephritis is lower with shorter durations of analgesic use, making diclofenac a potentially acceptable option for CKD patients 3.

Considerations for Diclofenac Use

• The use of diclofenac in CKD patients should be individualized, taking into account the patient's glomerular filtration rate and other comorbid conditions 4.
• Diclofenac is worthy of consideration in mild to moderate cases of CKD, but its use should be carefully evaluated and monitored 3.
• The potential benefits and risks of diclofenac use in CKD patients should be weighed, considering the limited safety data available for this population 4.

Comparison with Other NSAIDs

• COX-2 inhibitors, including diclofenac, may produce effects on renal function similar to nonselective NSAIDs, which inhibit both COX-1 and COX-2 5.
• The renal safety benefits of COX-2 inhibitors over nonselective NSAIDs are unlikely, and all NSAIDs, including COX-2-selective inhibitors, may share a similar risk for adverse renal effects 5.