What are the adjunctive therapies besides acetaminophen (Tylenol) for managing pain in patients with diverticulitis?

Adjunctive Therapies for Diverticulitis Pain Management

Beyond acetaminophen, the primary adjunctive therapies for diverticulitis pain management include dietary modification with a clear liquid diet during the acute phase, osmotic laxatives like MiraLAX to maintain soft stools, and for chronic post-diverticulitis pain, low to modest doses of tricyclic antidepressants to address visceral hypersensitivity. 1

Acute Phase Management

Dietary Modification

• A clear liquid diet during the acute phase helps reduce pain by minimizing mechanical irritation of the inflamed colon, with advancement as symptoms improve 1
• This dietary approach naturally helps reduce pain as the inflammatory process resolves 1

Osmotic Laxatives

• MiraLAX (polyethylene glycol) can be safely used in patients with diverticulitis as there is no contraindication in current major gastroenterology guidelines 2
• MiraLAX works gently by drawing water into the colon without causing forceful contractions that could worsen inflammation 2
• The medication does not increase intra-colonic pressure significantly, which is the primary mechanical concern in diverticulitis 2
• Maintaining soft, regular stools with MiraLAX may reduce straining and intra-colonic pressure 2

Chronic Pain Management (Post-Acute Episode)

Tricyclic Antidepressants

• For persistent pain after the acute episode resolves, low to modest doses of tricyclic antidepressants may be considered for visceral hypersensitivity 1
• 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
• Before initiating tricyclic antidepressants, exclude ongoing inflammation with imaging and lower endoscopy to ensure symptoms are not due to recurrent inflammation 1

Critical Medications to AVOID

NSAIDs (Non-Aspirin)

• The American Gastroenterological Association advises patients with diverticulitis to avoid non-aspirin NSAIDs (conditional recommendation, very-low quality evidence) 1
• Non-aspirin NSAIDs are associated with a moderately increased risk of both incident diverticulitis episodes AND complicated diverticulitis 1
• This risk is greater for non-aspirin NSAIDs than for aspirin, making ketorolac (Toradol) particularly concerning 1

Aspirin Exception

• Unlike other NSAIDs, aspirin may be continued if indicated for cardiovascular protection (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

Opioids

• Opioids should be avoided when possible as they are associated with increased risk of diverticulitis 3
• Hydrocodone/acetaminophen should be reserved only for pain severe enough to require an opioid analgesic when alternative treatments are inadequate 4

Therapies WITHOUT Evidence Support

Medications to Avoid Prescribing

• The American Gastroenterological Association recommends against routine use of mesalamine for pain control after acute diverticulitis, as evidence does not support its efficacy 1
• Rifaximin is not recommended for pain management in acute diverticulitis as evidence does not support its routine use 1
• Probiotics are not recommended for pain management in acute diverticulitis as evidence does not support their routine use 1

Long-Term Prevention Strategies

Lifestyle Modifications

• Patients with diverticular disease should be encouraged to engage in vigorous physical activity 1
• A high-fiber diet (or fiber supplementation) is the preferred long-term approach, with MiraLAX serving as a bridge therapy or adjunct if patients cannot tolerate adequate dietary fiber initially 2
• Fiber supplementation is recommended after acute diverticulitis resolves to prevent recurrence 2

Common Pitfalls

• Do not prescribe non-aspirin NSAIDs for pain control - they increase both diverticulitis episodes and complications 1
• Do not assume chronic abdominal pain represents recurrent diverticulitis - 45% of patients have visceral hypersensitivity rather than inflammation 1
• Do not use stimulant laxatives - osmotic agents like MiraLAX are preferred for patients with diverticulitis 2
• Do not prescribe mesalamine, rifaximin, or probiotics for pain management - evidence does not support their use 1