Do Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) exacerbate diverticulitis?

NSAIDs and Diverticulitis: Effects and Recommendations

Non-aspirin NSAIDs should be avoided in patients with a history of diverticulitis as they moderately increase the risk of diverticulitis occurrence and complications. 1

Effects of NSAIDs on Diverticulitis

Non-Aspirin NSAIDs

• Observational studies indicate that non-aspirin NSAIDs are associated with:
  • Moderately increased risk of occurrence of any episode of diverticulitis 1
  • Increased risk of complicated diverticulitis 1
  • Independent risk factor for diverticulitis (OR 3.2,95% CI 1.5-6.9) 2

Aspirin vs. Non-Aspirin NSAIDs

• Aspirin has a different risk profile than non-aspirin NSAIDs:
  • Aspirin shows only slightly increased risk of diverticulitis (relative risk 1.25; 95% CI 0.61-2.10) 1
  • Non-aspirin NSAIDs carry a greater risk for diverticulitis than aspirin 1
  • Selective association of non-aspirin NSAIDs with diverticulitis has been demonstrated 2

Mechanism of NSAID-Related Complications

NSAIDs may cause damage to the colon through:

• Inducing non-specific colitis 3
• Exacerbating colonic diverticulitis 3
• Potentially increasing risk of perforation 4

Clinical Management Algorithm

1. For patients with history of diverticulitis:

   • Avoid non-aspirin NSAIDs if possible 1
   • Consider alternative pain management options

2. For patients requiring aspirin for cardiovascular protection:

   • Continue aspirin therapy as benefits may outweigh risks 1
   • Consider the modest protective effects of aspirin on overall mortality and nonfatal myocardial infarction 1

3. For patients with active diverticulitis currently taking NSAIDs:

   • Discontinue NSAIDs during the acute episode 3
   • Consider alternative pain management strategies

Special Considerations

• Risk stratification: Patients with diverticulosis who require NSAIDs should be informed of the increased risk of developing diverticulitis 5

• Perioperative period: Use NSAIDs with caution in patients with known diverticulosis who are undergoing surgery, as cases of perforation have been reported 4

• Preventive measures: Patients with history of diverticulitis should focus on:

  • Consuming a high-quality diet high in fiber
  • Achieving/maintaining normal BMI
  • Regular physical activity
  • Avoiding smoking 1

Pitfalls and Caveats

• The evidence regarding NSAIDs and diverticulitis is primarily from observational studies with very low quality of evidence 1

• Do not confuse the recommendations for aspirin and non-aspirin NSAIDs, as they have different risk profiles 1

• While NSAIDs should be avoided when possible in patients with history of diverticulitis, the recommendation is conditional rather than strong, reflecting the quality of available evidence 1

• Avoid the outdated practice of recommending patients with diverticulitis to avoid nuts, popcorn, or seeds, as this has been debunked by modern data 1, 6