Can diclofenac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) be administered intravenously (IV)?

Intravenous Administration of Diclofenac

Yes, diclofenac can be administered intravenously (IV), with specific formulations designed for this route of administration that have been shown to be effective for acute pain management.

IV Diclofenac Formulations

Diclofenac is available in specific IV formulations that allow for intravenous administration:

• A novel formulation of injectable diclofenac sodium (Dyloject®) solubilized with hydroxypropyl β-cyclodextrin (HPβCD) can be given as a small volume IV bolus 1
• Traditional IV diclofenac formulations have been available in Europe and other countries for many years, typically administered over 30-120 minutes 1

Dosage and Administration Guidelines

When administering diclofenac intravenously, the following guidelines should be followed:

• Initial dose should not exceed 1.5 mg/kg (calculated using ideal body weight) given as an infusion over 10 minutes 2
• Maintenance infusion should not exceed 1.5 mg/kg/h for no longer than 24 hours 2
• For any patient, no more than 120 mg/h should be infused 2
• Common effective doses range from 18.75 mg to 75 mg 3, 1
• IV diclofenac should be delivered through a separate, dedicated cannula 2

Efficacy

IV diclofenac has demonstrated significant efficacy for acute pain management:

• In postoperative settings, IV diclofenac provides good pain relief for the majority of patients 3
• Studies show that IV diclofenac significantly reduces pain intensity compared to placebo 3, 1
• IV diclofenac reduces the need for rescue opioid medications, which can decrease opioid-related adverse events 3, 1
• The onset of action is relatively quick, with a terminal half-life of approximately 2 hours 4

Safety Considerations and Contraindications

Important safety considerations when using IV diclofenac include:

• Cardiovascular risk: Diclofenac carries cardiovascular risks similar to other NSAIDs, with meta-analyses showing a higher risk of vascular events (RR 1.63,95% CI 1.12-2.37) compared to naproxen 5, 2
• Contraindications: IV diclofenac is contraindicated in patients with:
  • Aspirin/NSAID-induced asthma
  • Pregnancy
  • Cerebrovascular hemorrhage
  • Bleeding disorders
  • Recent coronary artery bypass graft (CABG) surgery 5, 2
  • Patients weighing <40 kg 2
• Monitoring requirements: Patients should be closely monitored during IV diclofenac administration, particularly those with existing comorbidities 2
• Ideally, patients should be managed in a monitored bed space in a high dependency unit (level 2 care) 2

Implementation in Clinical Practice

For proper implementation of IV diclofenac in clinical practice:

• Use should be approved by the local hospital and medication governance committee before implementation 2
• A separate monitoring chart should be maintained for IV diclofenac administration 2
• Lipid emulsion 20% should be readily available wherever IV diclofenac is used 2
• Concomitant use with other local anesthetic interventions is contraindicated, and IV diclofenac should not be started within 4 hours after any nerve block 2

IV diclofenac provides an effective alternative for pain management when oral administration is not feasible or when rapid onset of action is required, but must be used with appropriate caution regarding cardiovascular and other risks.