What is the treatment for rectal diclofenac (nonsteroidal anti-inflammatory drug (NSAID))-induced rectal bleeding?

Treatment of Rectal Diclofenac-Induced Rectal Bleeding

Discontinuation of rectal diclofenac is the first and most essential step in treating rectal diclofenac-induced rectal bleeding, followed by assessment of bleeding severity and appropriate supportive measures. 1

Initial Assessment and Management

• Perform a focused assessment to determine the severity of bleeding, including vital signs, hemoglobin level, and clinical signs of hemodynamic instability 1
• For severe bleeding, maintain hemoglobin level >7 g/dL and mean arterial pressure >65 mmHg while avoiding fluid overload 1
• Investigate with flexible endoscopy to determine the exact cause and location of the bleeding 2
• Optimize bowel function and stool consistency which may reduce the amount of bleeding 2

Specific Treatment Options

• For mild bleeding that doesn't affect quality of life, discontinue diclofenac and provide reassurance without further intervention 2
• For bleeding that affects quality of life, consider the following interventions:
  • Stop/reduce any anticoagulants if possible 2
  • Initiate sucralfate enemas if bleeding is severe (2g sucralfate suspension mixed with 30-50ml water administered rectally twice daily) 2
  • NSAIDs for short-term treatment (5-7 days) may help control bleeding, though this seems counterintuitive in NSAID-induced bleeding 2

Alternative Pain Management

• Consider acetaminophen/paracetamol as first-line alternative for pain management 1
• For inflammatory conditions requiring anti-inflammatory effects, a short course of corticosteroids may be considered as they do not increase ulcer risk when used alone 2
• If stronger analgesia is needed, consider short-term use of opioids with appropriate monitoring 1

Preventive Measures for Future Use

• If NSAIDs must be used in the future, consider:
  • Using the lowest effective dose for the shortest possible duration 2, 3
  • Co-administration of gastroprotective agents such as proton pump inhibitors (PPIs) or misoprostol 2, 1
  • Avoiding combination NSAID therapy, particularly with aspirin 2, 3
  • Testing for and treating Helicobacter pylori if present 2, 4

Monitoring and Follow-up

• Monitor for continued bleeding and signs of hemodynamic instability 1
• Check complete blood count to assess for anemia 1
• If bleeding persists despite conservative measures, consider:
  • Endoscopic evaluation to identify the source and provide local treatment 2, 1
  • For severe persistent bleeding, endoscopic interventions such as argon plasma coagulation may be considered, though with caution due to potential complications (7-26% serious complication rate) 2

Special Considerations

• NSAID-induced colorectal ulcerations may be under-recognized but are clinically significant 5
• Rectal diclofenac can cause significant bleeding even at lower doses (25mg) 6
• Systemic absorption of diclofenac from topical and rectal formulations can occur, potentially causing GI bleeding 7, 8
• In very high-risk patients with prior ulcer complications, NSAIDs should be avoided entirely if possible 2

Pitfalls and Caveats

• Argon plasma coagulation, while often considered a treatment of choice by gastroenterologists, should be used with extreme caution due to high complication rates (up to 26%) in ischemic tissues 2
• Continued use of any NSAID, even topical or rectal formulations, can worsen bleeding due to systemic absorption 7
• Patients with comorbidities such as renal failure, liver cirrhosis, or cerebrovascular disease are at higher risk for complications from NSAID-induced bleeding 5