What are the guidelines for using diclofenac (Non-Steroidal Anti-Inflammatory Drug (NSAID)) in patients with viral infections?

Guidelines for Diclofenac Use in Viral Infections

NSAIDs, including diclofenac, should be used with extreme caution in patients with viral infections due to potential risks of decreased host defense and serious infectious complications. 1

Risk Assessment for NSAID Use in Viral Infections

The decision to use diclofenac in patients with viral infections should be based on careful risk stratification:

Low-Risk Patients (no risk factors)

• Use the least ulcerogenic NSAID at the lowest effective dose
• Consider alternatives to NSAIDs when possible
• If NSAID needed, ibuprofen may be preferred over diclofenac based on safety profile 1

Moderate-Risk Patients (1-2 risk factors)

• Risk factors include: age ≥60 years, history of peptic ulcer, concomitant medications
• Use NSAID plus gastroprotection (PPI preferred) 1
• Consider COX-2 inhibitor as an alternative

High-Risk Patients (≥3 risk factors or concomitant aspirin/anticoagulants)

• Avoid NSAIDs if possible
• If NSAID necessary, use COX-2 inhibitor plus PPI 1

Specific Recommendations for COVID-19

For patients with COVID-19 specifically:

• Patients should be advised against NSAID self-medication when COVID-19-like symptoms begin 1
• NSAIDs should be used with extreme caution in COVID-19 patients 1
• For severe COVID-19 with kidney, cardiac, or gastrointestinal injury, NSAIDs should be stopped 1
• For mild COVID-19, there is low consensus on whether NSAIDs should be stopped 1

Therapeutic Considerations

When diclofenac is deemed necessary for viral infection symptoms:

• Use the lowest effective dose for the shortest duration possible
• For fever reduction in viral pharyngitis, diclofenac potassium 12.5mg has been shown to be the lowest effective single dose 2
• Diclofenac has demonstrated efficacy for symptom relief in viral infections comparable to other NSAIDs 3, 4
• Monitor for adverse effects, particularly gastrointestinal, cardiovascular, and renal complications 1

Gastroprotection Strategies

If diclofenac must be used in patients with viral infections:

• For moderate-risk patients: Add PPI (preferred) or misoprostol 1
• For high-risk patients: Consider COX-2 inhibitor plus PPI instead of diclofenac 1
• PPIs are superior to H2-receptor antagonists for gastroprotection 5

Monitoring Recommendations

For patients on diclofenac during viral infections:

• Regular assessment for GI symptoms (abdominal pain, dyspepsia, melena)
• Periodic monitoring of renal function, especially in patients with risk factors
• Blood pressure monitoring, as NSAIDs can worsen hypertension 1
• Consider fecal occult blood testing for high-risk patients 5

Common Pitfalls to Avoid

1. Failure to recognize drug interactions between NSAIDs and antiviral medications 1
2. Overlooking cardiovascular risks of diclofenac, which has a higher CV risk profile than some other NSAIDs 1
3. Not providing adequate gastroprotection in at-risk patients
4. Using NSAIDs in severe viral infections with organ dysfunction
5. Prolonged use of NSAIDs during viral infections without reassessment

Alternative Approaches

For symptom management in viral infections when NSAIDs are contraindicated:

• Acetaminophen/paracetamol as first-line for fever and pain 1
• Use caution with acetaminophen in patients with liver dysfunction 1
• For severe pain, consider short-term opioid analgesics under close supervision
• Non-pharmacological approaches: rest, adequate hydration, and supportive care

By following these guidelines, clinicians can make informed decisions about the appropriate use of diclofenac in patients with viral infections, balancing symptom relief against potential risks.