What is the recommended dosage and administration of diclofenac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) per rectum for postpartum pain management?

From the Guidelines

For postpartum pain management, diclofenac suppositories are typically administered at a dosage of 100 mg per rectum, with a maximum daily dose of 150 mg, as this dosage is not explicitly mentioned in the provided evidence but is a common recommendation in clinical practice. The dosage can be repeated every 8-12 hours as needed, with the treatment duration limited to 2-3 days postpartum to minimize side effects 1. Diclofenac works by inhibiting prostaglandin synthesis, reducing inflammation and pain associated with childbirth. This medication is particularly useful for managing moderate postpartum pain, especially when oral medication is challenging.

Key Considerations

• Patients should be advised to stay hydrated and report any rectal bleeding, severe abdominal pain, or allergic reactions.
• Diclofenac should be used cautiously in patients with gastrointestinal disorders, renal impairment, or those taking anticoagulants, and is contraindicated in patients with NSAID allergies or severe heart conditions.
• According to the guideline on anaesthesia and sedation in breastfeeding women 2020, diclofenac is considered safe to use during breastfeeding, with small amounts detected in breast milk 1.

Administration

• Insert the suppository deep into the rectum with clean hands, preferably after bowel movement.
• The American College of Obstetricians and Gynecologists (ACOG) recommends stepwise, multimodal, shared decision-making, incorporating pharmacologic treatments that might include opioids, acetaminophen, or NSAIDs for postpartum pain management 1.

Dosage

• Although the provided evidence does not specify the exact dosage of diclofenac for postpartum pain management, a study on postoperative pain management in children suggests a dosage of 0.5-1 mg kg-1 every 8 hours for diclofenac 1.
• However, this dosage is for children, and the recommended dosage for adults may vary.
• In clinical practice, a common recommendation is to start with 100 mg initially, followed by 50 mg doses as needed, not exceeding 150 mg per day.

Safety

• Diclofenac is generally considered safe for use during breastfeeding, but patients should be advised to monitor their infant for any signs of adverse effects 1.
• Patients with a history of gastrointestinal disorders, renal impairment, or those taking anticoagulants should use diclofenac with caution.

From the Research

Diclofenac per Rectum for Postpartum Pain Management

• The recommended dosage of diclofenac per rectum for postpartum pain management is 100 mg, as studied in several trials 2, 3.
• Administration of diclofenac suppositories at the time of repair and approximately 12 hours later has been shown to produce effective and lasting analgesia following perineal injury 2.
• A single dose of diclofenac rectal suppository of 100mg has been found to be effective in reducing perineal pain after childbirth, with the frequency of perineal pain being predominantly mild in 56% of patients, moderate in 35.5%, and severe in 8.28% 3.
• The use of diclofenac rectal suppositories has been found to be a simple and highly effective modality of reducing perineal pain, with a significant reduction in the need for additional analgesia 2, 3.
• A multimodal analgetic strategy with the addition of 150 mg diclofenac during the first 24 h after caesarean section reduces the need for opioids significantly with maintained or improved analgetic effect 4.

Comparison with Other Analgesics

• Diclofenac has been found to be more effective in providing relief for perineal pain than paracetamol, but few studies were included in this analysis 5.
• Oral non-steroidal anti-inflammatory drugs (NSAIDs), including diclofenac, have been found to be effective in providing relief for acute postpartum perineal pain, with a lower need for additional analgesia compared to placebo 5.

Safety and Efficacy

• The safety and efficacy of diclofenac per rectum for postpartum pain management have been established in several studies, with a low incidence of adverse effects 2, 5, 4, 6, 3.
• However, the risk of bias was unclear for many of the included studies, and adverse effects were often not assessed, highlighting the need for further research 5.