Can diclofenac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) or aceclofenac (NSAID) be given to a 45-year-old female with abdominal pain, known coronary artery disease (CAD) with status post angioplasty, and currently taking clopidogrel (Antiplatelet), enalapril (Angiotensin-Converting Enzyme (ACE) inhibitor), and atorvastatin (HMG-CoA reductase inhibitor)?

Diclofenac and Aceclofenac Are Contraindicated in a 45-Year-Old Female with CAD on Clopidogrel

Diclofenac and aceclofenac should NOT be given to this 45-year-old female with CAD, post-angioplasty, and on clopidogrel, enalapril, and atorvastatin due to significantly increased cardiovascular thrombotic risk and potential drug interactions. 1

Cardiovascular Risk Considerations

• NSAIDs, including diclofenac and aceclofenac, cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal 1
• Diclofenac is specifically contraindicated in patients with coronary artery disease, especially those with a history of myocardial infarction 1
• The FDA explicitly warns that NSAIDs may cause increased risk of cardiovascular events that can occur early in treatment and may increase with duration of use 1
• The risk of adverse cardiovascular outcomes is amplified in patients with established cardiovascular disease 2

Drug Interaction Concerns

• Concomitant use of diclofenac/aceclofenac with antiplatelet agents like clopidogrel significantly increases bleeding risk 1
• The combination of NSAIDs with clopidogrel has a synergistic effect on bleeding, with a 3-6 times increased risk of GI bleeding compared to using either drug alone 1, 2
• NSAIDs may diminish the antihypertensive effect of ACE inhibitors like enalapril, potentially compromising blood pressure control 1
• In patients with renal impairment, co-administration of NSAIDs with ACE inhibitors may result in deterioration of renal function, including possible acute renal failure 1

Alternative Pain Management Options

• For abdominal pain management in this high-risk patient, a stepped-care approach should be used 2:
  1. First-line: Acetaminophen, small doses of narcotics, or non-acetylated salicylates 2
  2. If first-line therapy is insufficient and the patient has low thrombotic risk (which this patient does not have), non-selective NSAIDs like naproxen might be considered 2

Special Considerations for This Patient

• The patient is on triple therapy (antiplatelet + ACE inhibitor + statin), which is standard post-angioplasty treatment, and adding an NSAID would significantly increase risk 2
• Post-angioplasty patients require careful medication management to prevent stent thrombosis and recurrent cardiovascular events 2
• The patient's current medications (clopidogrel, enalapril, and atorvastatin) are essential for secondary prevention of cardiovascular events and should not be compromised by adding medications with potential interactions 2

Monitoring If Pain Management Is Absolutely Necessary

• If pain control is absolutely necessary and no alternatives are effective, and a decision is made to use NSAIDs (which is not recommended):
  • Use the lowest effective dose for the shortest possible duration 2
  • Monitor blood pressure closely to ensure desired blood pressure is maintained 1
  • Monitor for signs of worsening renal function 1
  • Consider adding a proton pump inhibitor to reduce GI bleeding risk 2
  • Remain vigilant for signs of cardiovascular events throughout treatment 1

In conclusion, the risks of administering diclofenac or aceclofenac to this patient with CAD on clopidogrel, enalapril, and atorvastatin far outweigh any potential benefits. Alternative pain management strategies should be pursued.