Is it safe to use diclofenac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) for 2 weeks in patients with intractable radicular pain?

Can Diclofenac Be Used for 2 Weeks in Intractable Radicular Pain?

Yes, diclofenac can be safely used for 2 weeks in patients with intractable radicular pain, as short-term NSAID use (2-4 weeks) is supported by guideline evidence for inflammatory spinal conditions and radicular pain, though efficacy data specific to radicular pain is limited. 1

Evidence Supporting Short-Term Use

The most recent guideline evidence from 2025 explicitly recommends NSAIDs including diclofenac at maximum tolerated doses for 2-4 weeks as first-line treatment for spinal inflammatory conditions, with treatment response evaluation at this timeframe. 1 While this guideline addresses chronic non-bacterial osteitis, the principle of short-term NSAID trials for spinal pain is well-established.

Dosing for radicular pain:

• Diclofenac starting at 150 mg/day in divided doses, with maintenance of 75-100 mg/day in divided doses 1
• Treatment response should be evaluated at 2-4 weeks 1

Safety Considerations for 2-Week Use

Cardiovascular Risk

The cardiovascular risks of diclofenac are dose-dependent and increase with duration of use, particularly beyond the first 6 months. 1, 2 For a 2-week course:

• Diclofenac carries increased cardiovascular risk compared to other NSAIDs, with a relative risk of 1.63 for vascular events versus placebo 3
• The risk is highest in the first 6 months but remains present even with short-term use 1
• Contraindicated in patients with recent myocardial infarction or coronary artery bypass graft surgery 3, 2

Gastrointestinal Risk

Short-term NSAID use carries lower but still present GI risk:

• Upper GI ulcers, bleeding, or perforation occur in approximately 1% of patients treated for 3-6 months 2
• Short-term therapy (2 weeks) has substantially lower risk, but is not risk-free 2
• Risk factors requiring caution: prior peptic ulcer disease, GI bleeding history, concomitant corticosteroids, anticoagulants, SSRIs, smoking, alcohol use, older age 2

Hepatotoxicity

• Meaningful transaminase elevations (>3x ULN) occur in about 2-4% of patients on diclofenac 2
• Most elevations occur in the first 2 months, with 42 of 51 patients developing marked elevations within this timeframe 2
• For a 2-week course, baseline liver function is reasonable but repeat testing is not typically necessary unless symptoms develop 2

Clinical Algorithm for 2-Week Diclofenac Use

Pre-treatment screening:

1. Exclude recent MI (within 1 year), coronary artery bypass graft surgery, or high cardiovascular risk 3, 2
2. Screen for active peptic ulcer disease, history of GI bleeding, or multiple GI risk factors 2
3. Check baseline renal function and liver enzymes if planning longer courses 2
4. Review concomitant medications (anticoagulants, aspirin, SSRIs, corticosteroids) 2

If proceeding with treatment:

• Start diclofenac 75-150 mg/day in divided doses 1
• Use lowest effective dose 1
• Consider gastroprotection (PPI or misoprostol) if any GI risk factors present 1
• Evaluate response at 2 weeks 1

Monitoring during 2-week course:

• Watch for signs of GI bleeding (melena, hematemesis, abdominal pain) 2
• Monitor for hepatotoxicity symptoms (nausea, fatigue, jaundice, right upper quadrant pain) 2
• Assess for cardiovascular symptoms (chest pain, dyspnea) 2

Efficacy in Radicular Pain

Evidence for NSAIDs specifically in radicular pain is limited:

• The American College of Physicians found insufficient evidence for NSAIDs in radicular low back pain due to inconsistent results 1
• One case series reported successful treatment of radicular pain with topical diclofenac formulation, though this was a compounded preparation 4
• Diclofenac has unique spinal antinflammatory properties through PPAR-γ activation, COX-2 inhibition, and neuronal K+ channel blockage that may benefit radicular pain 5

Despite limited specific evidence for radicular pain, a 2-week trial is reasonable given:

• Established efficacy in other pain conditions 6
• Low risk with short-term use in appropriate patients 7
• Guideline support for short-term NSAID trials in spinal conditions 1

Key Contraindications and Pitfalls

Absolute contraindications:

• Recent MI or perioperative CABG surgery 3, 2
• Active GI bleeding or perforation 2
• Advanced liver disease with coagulopathy 2

Relative contraindications requiring careful risk-benefit assessment:

• Heart failure or significant edema 2
• Uncontrolled hypertension 1
• Chronic kidney disease 2
• History of peptic ulcer disease without gastroprotection 2

Common pitfall: Continuing beyond 2-4 weeks without reassessing efficacy and safety. If insufficient response at 2 weeks, consider alternative treatments rather than prolonging NSAID use. 1