Can we give diclofenac (nonsteroidal anti-inflammatory drug, NSAID) to an asthmatic patient for pain control?

Diclofenac Should Not Be Given to Asthmatic Patients Due to Risk of Bronchospasm

Diclofenac and other NSAIDs are contraindicated in patients with asthma who have a history of aspirin or NSAID sensitivity due to the significant risk of potentially life-threatening bronchospasm. 1, 2

Understanding NSAID-Induced Respiratory Reactions in Asthmatics

Aspirin and NSAIDs, including diclofenac, can cause respiratory deterioration in approximately 10% of adults with asthma 3. This reaction, known as aspirin-exacerbated respiratory disease (AERD) or NSAID-exacerbated respiratory disease (NERD), occurs through inhibition of the COX-1 enzyme, which shunts arachidonic acid down the leukotriene pathway, triggering bronchoconstriction 2.

The FDA label for diclofenac explicitly states it is contraindicated in:

• Patients with known hypersensitivity to diclofenac
• Patients with a history of asthma, urticaria, or allergic reactions after taking aspirin or other NSAIDs 1

Risk Assessment for Asthmatics

The risk of NSAID-induced respiratory reactions is particularly high in asthmatics with:

• Severe asthma
• Nasal polyps
• Chronic rhinosinusitis 2, 4

In these high-risk patients, the prevalence of aspirin-exacerbated respiratory disease can be as high as 21% 2. Even topical NSAIDs have been shown to worsen asthma control in sensitive individuals 4.

Case Evidence

A documented case report describes a 60-year-old man with a history of nasal polyposis who developed hypoxemic respiratory failure after taking diclofenac prior to sinus surgery. He was diagnosed with acute asthma exacerbation due to diclofenac and required treatment with oxygen, nebulized bronchodilators, and prednisolone 5.

Alternative Pain Management Options for Asthmatics

For pain control in asthmatic patients, consider these alternatives in order of preference:

1. Acetaminophen (first choice):

   • Generally well-tolerated by most asthmatics
   • Rarely associated with cross-sensitivity
   • Use standard dosing (e.g., 500-1000 mg every 4-6 hours, not exceeding 4g daily) 2, 6

2. Non-acetylated salicylates:

   • May be used if acetaminophen is insufficient 2

3. Low-dose opioids:

   • For moderate to severe pain when acetaminophen is insufficient
   • Use with caution due to risk of respiratory depression 2

4. Tramadol:

   • Has reduced respiratory depressive effects compared to other opioids
   • Monitor for confusion, especially in older patients 2

Important Caveats and Monitoring

• Even acetaminophen can cause respiratory symptoms in a small proportion of NSAID-intolerant asthmatics, particularly at high doses 3
• The only definitive way to diagnose NSAID sensitivity is through formal aspirin challenge testing, which should be performed under medical supervision 2, 6
• For patients with asthma who have never used NSAIDs before, treat them as potentially intolerant and only use NSAIDs under close medical supervision 3
• Patients with asthma who regularly use NSAIDs without problems can continue but should be warned that intolerance can develop later in life 3

Conclusion

When managing pain in asthmatic patients, the evidence strongly supports avoiding diclofenac and other NSAIDs due to the risk of potentially severe respiratory reactions. Acetaminophen remains the safest first-line analgesic for these patients, with careful consideration of other options when additional pain control is needed.