What is the treatment for rectal bleeding induced by diclofenac (Non-Steroidal Anti-Inflammatory Drug, NSAID)?

Treatment of Rectal Diclofenac Induced Bleeding

The first-line treatment for rectal bleeding induced by diclofenac is immediate discontinuation of the medication, followed by assessment of bleeding severity and appropriate supportive care including proton pump inhibitor therapy. 1

Initial Assessment and Management

• Immediately discontinue diclofenac to prevent further gastrointestinal mucosal damage 1
• Assess hemodynamic stability and severity of bleeding - patients with orthostatic hypotension, decrease in hematocrit, or requiring blood products should be considered for hospital admission 1
• Correct any coagulopathy or thrombocytopenia with fresh frozen plasma or platelets respectively 1
• Determine transfusion requirements based on patient's age, rate of bleeding, and presence of comorbid conditions such as coronary artery disease 1
• Perform digital rectal examination to assess for anorectal pathology 1

Diagnostic Evaluation

• Consider colonoscopy to exclude other causes of rectal bleeding and potentially provide therapeutic intervention 1
• Evaluate for risk factors that may have contributed to bleeding, including:
  • Concurrent use of anticoagulants, antiplatelet drugs, or other NSAIDs 2, 3
  • History of previous gastrointestinal bleeding 1, 3
  • Advanced age (>75 years) 1, 3
  • H. pylori infection 1

Treatment

• For active bleeding, provide resuscitation with intravenous fluids and blood products as needed 1
• For persistent bleeding, consider endoscopic intervention 1
• Initiate proton pump inhibitor (PPI) therapy at high dose once bleeding is controlled 1, 4
• PPIs can reduce the risk of NSAID-related ulcers by up to 90% 1
• Consider H. pylori testing and eradication if positive 1, 4
• NSAIDs like diclofenac cause GI bleeding through direct mucosal damage and antiplatelet effects by inhibiting protective prostaglandins 5, 3

Prevention of Recurrence

• Avoid reintroduction of diclofenac or other NSAIDs if possible 1, 3
• If pain management is necessary, consider alternative analgesics with lower GI risk profile 1, 4
• If NSAID use is unavoidable, use the lowest effective dose for the shortest duration 1, 3
• Add gastroprotective therapy, with PPI therapy as the preferred option 1, 4
• Misoprostol (600 mg/day) is an alternative gastroprotective therapy but has more side effects 4, 1

Special Considerations

• Patients with a history of NSAID-induced rectal bleeding have a 5% risk of bleeding recurrence in the first six months if NSAIDs are continued 1, 3
• Elderly patients (>75 years) have significantly higher risk of serious GI bleeding compared to younger patients 2, 3
• Avoid combinations of NSAIDs including low-dose aspirin, other antiplatelet drugs, and anticoagulants as they significantly increase bleeding risk 2, 3
• The risk of GI bleeding with NSAIDs increases with longer duration of therapy 3
• Only one in five patients who develop serious GI adverse events on NSAID therapy is symptomatic, making prevention crucial 3

Important Cautions

• Topical NSAIDs such as diclofenac gel can also cause GI bleeding due to systemic absorption, though less commonly than oral formulations 6
• Even co-administration of PPIs with NSAIDs does not completely eliminate the risk of GI bleeding, as demonstrated by case reports of severe GI bleeding in patients taking fixed-dose combinations of rabeprazole and diclofenac 7
• NSAID-induced colorectal ulceration may be under-recognized and should be considered in patients with acute rectal bleeding, anemia, and lower GI complaints 8
• Monitor for signs of recurrent bleeding even after initial management 1