Is it safe to give a single dose of diclofenac (Nonsteroidal Anti-Inflammatory Drug) to a post-PTCA (Percutaneous Transluminal Coronary Angioplasty) patient for severe dental pain?

Avoid Diclofenac in Post-PTCA Patients—Use Acetaminophen or Naproxen Instead

A single dose of diclofenac should be avoided in a post-PTCA patient, even for severe dental pain, due to the significantly elevated cardiovascular risk associated with this specific NSAID in patients with established coronary artery disease. 1

Why Diclofenac is Particularly Dangerous

• Diclofenac carries the highest cardiovascular risk among NSAIDs, with meta-analyses showing a 63% increased risk of vascular events compared to placebo (RR 1.63,95% CI 1.12-2.37), and a 2.4-fold increased mortality risk in patients with prior MI (RR 2.40,95% CI 2.09-2.80). 1

• The FDA black box warning specifically states that NSAIDs increase the risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal, and that patients with cardiovascular disease or risk factors are at greater risk. 1

• Post-PTCA patients have established coronary artery disease and are by definition at high cardiovascular risk, making them precisely the population most vulnerable to diclofenac's prothrombotic effects. 1

Safer Alternatives for Severe Dental Pain

First-Line Recommendation: Acetaminophen

• Acetaminophen 1000 mg every 6 hours (maximum 3000 mg daily) is the safest option for post-PTCA patients, as it provides effective analgesia without cardiovascular or antiplatelet interference. 1

• Acetaminophen has been shown effective for severe dental pain and does not carry the cardiovascular risks of NSAIDs. 2

Second-Line Option: Naproxen (If Acetaminophen Insufficient)

• If acetaminophen alone is inadequate, naproxen is the preferred NSAID due to its more favorable cardiovascular profile compared to other NSAIDs (RR 0.92 for vascular events vs. placebo, 95% CI 0.67-1.26). 1

• Naproxen 220-440 mg has demonstrated superior efficacy to acetaminophen for dental pain while maintaining better cardiovascular safety than diclofenac or ibuprofen. 1, 3

• Use the lowest effective dose for the shortest duration possible—a single dose or maximum 2-3 days. 1

Combination Therapy for Severe Pain

• Ibuprofen 600 mg plus acetaminophen 1000 mg is more effective than either agent alone (ES = 34.89, P = .000) for severe dental pain, but ibuprofen still carries moderate cardiovascular risk (RR 1.51 for vascular events). 2

• If combination therapy is necessary, naproxen 220 mg plus acetaminophen 1000 mg is safer than ibuprofen combinations in post-PTCA patients. 3

Critical Antiplatelet Considerations

• Post-PTCA patients must continue dual antiplatelet therapy (DAPT) with aspirin 81 mg daily plus a P2Y12 inhibitor for at least 12 months, regardless of pain management needs. 1, 4

• Never discontinue DAPT to accommodate NSAID use—the risk of stent thrombosis leading to MI and death far outweighs bleeding concerns. 4

• Add a proton pump inhibitor (avoid omeprazole with clopidogrel due to CYP2C19 interaction) if any NSAID is used, to reduce GI bleeding risk from the combination of NSAID plus DAPT. 1, 4

Practical Algorithm for This Patient

1. Start with acetaminophen 1000 mg immediately, repeat every 6 hours as needed (maximum 3000 mg/24 hours). 1

2. If pain remains severe after 2 doses of acetaminophen, add naproxen 220-440 mg as a single dose or twice daily for maximum 2-3 days. 1, 3

3. Ensure patient is taking aspirin 81 mg daily and their prescribed P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel). 1, 4

4. Add or continue PPI therapy (pantoprazole or lansoprazole preferred if on clopidogrel) during any NSAID use. 1, 4

5. If pain persists despite this regimen, consider tramadol 50 mg as rescue analgesia rather than escalating NSAID doses. 3

Common Pitfalls to Avoid

• Do not assume "just one dose" of diclofenac is safe—even single doses can trigger acute cardiovascular events in high-risk patients. 1

• Do not use ibuprofen as a "safer" alternative—while better than diclofenac, it still carries significant cardiovascular risk (RR 1.51) compared to naproxen. 1

• Do not stop antiplatelet therapy to reduce bleeding risk—stent thrombosis is immediately life-threatening. 4

• Do not use COX-2 selective inhibitors (celecoxib, etoricoxib) as alternatives—they carry similar or greater cardiovascular risks than non-selective NSAIDs. 1