From the Guidelines
Diclofenac injections should generally be avoided in patients with chronic kidney disease (CKD). As a nonsteroidal anti-inflammatory drug (NSAID), diclofenac can worsen kidney function in CKD patients by reducing renal blood flow through inhibition of prostaglandin synthesis. This can lead to acute kidney injury, further deterioration of existing kidney disease, fluid retention, and electrolyte disturbances. According to the 2021 study 1, NSAIDs or COX-2 inhibitors should generally be avoided in patients with or at risk for CKD. Additionally, the 2014 study 1 suggests that NSAIDs should be avoided in patients with eGFR < 30 ml/min per 1.73 m2. If pain management is necessary for a CKD patient, safer alternatives should be considered first, such as acetaminophen (paracetamol), tramadol, or low-dose opioids depending on the severity of pain. If an NSAID is absolutely necessary, it should only be used at the lowest effective dose for the shortest possible duration with close monitoring of kidney function, and preferably after consultation with a nephrologist. Patients should be monitored for signs of worsening kidney function, including decreased urine output, edema, and rising serum creatinine levels. Adequate hydration should also be maintained during treatment to minimize kidney stress.
Some key points to consider when managing pain in CKD patients include:
- Avoiding NSAIDs and COX-2 inhibitors whenever possible, as recommended by the 2010 study 1
- Using alternative pain management options, such as acetaminophen or tramadol, as suggested by the 2006 study 1
- Monitoring kidney function closely when using NSAIDs, as recommended by the 2014 study 1
- Maintaining adequate hydration to minimize kidney stress, as suggested by the 2006 study 1
Overall, the use of diclofenac injections in CKD patients should be approached with caution, and alternative pain management options should be considered first. If diclofenac is necessary, it should be used at the lowest effective dose for the shortest possible duration, with close monitoring of kidney function.
From the FDA Drug Label
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. 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
The FDA drug label does not provide information on the use of injection diclofenac in patients with chronic kidney disease (CKD). The label only discusses the use of diclofenac potassium tablets. Therefore, no conclusion can be drawn about the use of injection diclofenac in CKD patients based on the provided drug labels 2 2.
From the Research
Use of Diclofenac 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.
- However, diclofenac has a shorter half-life and high efficacy, which may make it a suitable alternative for pain management in CKD patients 3.
Risks Associated with NSAID Use in CKD Patients
- NSAID use has been associated with acute kidney injury, progressive loss of glomerular filtration rate in CKD, electrolyte derangements, and hypervolemia with worsening of heart failure and hypertension 4.
- The risk of nephrotoxicity syndromes differs between levels of glomerular filtration rate and is modified by many comorbid conditions, risk factors, and characteristics of use 4.
- CKD patients using NSAIDs, including diclofenac, should be carefully monitored for signs of nephrotoxicity and other adverse effects 4.
Management of Pain in CKD Patients
- Pain management in CKD patients is challenging due to the limited safety data for use of analgesics in this population 4.
- The use of acetaminophen, aspirin, and non-selective NSAIDs has been associated with an increased risk of progression to end-stage renal disease (ESRD) in CKD patients 5.
- Optimal management of CKD includes avoidance of potential nephrotoxins, such as NSAIDs, and adjustments to drug dosing 6.