What can be prescribed for pain management in diverticulitis?

Pain Management for Diverticulitis

Acetaminophen is the primary and preferred analgesic for pain control in diverticulitis, while non-aspirin NSAIDs should be avoided due to their association with increased risk of diverticulitis episodes and complications. 1

Primary Pain Management Approach

• Prescribe acetaminophen as first-line analgesia for patients with acute diverticulitis, as recommended by the American Gastroenterological Association 1, 2
• Acetaminophen provides adequate pain control without the risks associated with NSAIDs 1, 3
• A clear liquid diet during the acute phase helps reduce pain by minimizing mechanical irritation of the inflamed colon 1

Medications to Avoid

• Non-aspirin NSAIDs (including ketorolac/Toradol, ibuprofen, naproxen) should be avoided as they are associated with a moderately increased risk of both incident diverticulitis episodes AND complicated diverticulitis 1
• The risk is greater for non-aspirin NSAIDs than for aspirin, making ketorolac particularly concerning 1
• Observational studies demonstrate that non-aspirin NSAIDs show a moderately increased risk of occurrence of any episode of diverticulitis AND complicated diverticulitis 1

Important Exception for Aspirin

• Aspirin may be continued if indicated for cardiovascular protection, as the AGA suggests against routinely advising patients to avoid aspirin (the risk increase is slight: RR 1.25,95% CI 0.61-2.10) 1
• The modest protective effects of aspirin on overall mortality and nonfatal myocardial infarction outweigh the slight diverticulitis risk in patients with cardiovascular indications 1

Chronic Pain Management After Acute Episode

• Approximately 45% of patients report periodic abdominal pain at 1-year follow-up after an episode of acute diverticulitis, likely due to visceral hypersensitivity 1, 2
• For persistent pain after the acute episode resolves, low to modest doses of tricyclic antidepressants may be considered for visceral hypersensitivity 1, 4
• Before attributing symptoms to visceral hypersensitivity, exclude ongoing inflammation with imaging and lower endoscopy 1, 4

Dietary Modifications for Pain Relief

• Advance diet as symptoms improve, which naturally helps reduce pain 1
• Initial clear liquid diet during acute phase, progressing as tolerated 1, 4

Common Pitfalls to Avoid

• Do not prescribe mesalamine for pain control after acute diverticulitis, as evidence does not support its efficacy 1
• Do not prescribe rifaximin for pain management in acute diverticulitis as evidence does not support its routine use 1
• Do not prescribe probiotics for pain management in acute diverticulitis as evidence does not support their routine use 1
• Avoid opiates when possible, as these medications are associated with increased risk of diverticulitis 4

Antibiotic Considerations (Not for Pain, But for Infection)

While antibiotics are not analgesics, they may be necessary in specific situations:

• Antibiotics should be added selectively rather than routinely, specifically for patients with comorbidities, frailty, immunocompromised status, age >80 years, or elevated inflammatory markers (CRP >140 mg/L or WBC >15 × 10^9 cells per liter) 1, 4
• For uncomplicated diverticulitis in immunocompetent patients without systemic symptoms, antibiotics are not recommended as first-line therapy 4, 3
• When antibiotics are indicated, oral options include amoxicillin-clavulanate or ciprofloxacin plus metronidazole for 4-7 days 4, 3