What is the recommended dose of diclofenac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) for an adult patient with potential gastrointestinal issues, kidney disease, or bleeding disorders, prior to stent removal in urology?

Diclofenac Dosing for Ureteral Stent Removal

For adult patients undergoing ureteral stent removal, administer 75 mg oral diclofenac 1 hour before the procedure.

Evidence-Based Dosing Protocol

The most direct evidence comes from a randomized controlled trial specifically evaluating diclofenac for DJ stent removal, which demonstrated that 75 mg oral diclofenac given 1 hour preprocedurally significantly reduced pain during cystoscopy (median VAS 30 vs 60, P<0.001), at first void (median VAS 30 vs 70, P<0.001), and at 24 hours post-procedure (median VAS 20 vs 40, P<0.001) compared to placebo 1.

Administration Timing and Route

• Give 75 mg oral diclofenac exactly 1 hour before the procedure to allow adequate absorption and peak analgesic effect 1
• Oral administration is preferred over parenteral routes for this outpatient procedure 1
• This single preemptive dose provides pain control during the procedure and for 24 hours afterward 1

Safety Considerations in High-Risk Populations

Gastrointestinal Risk

• Avoid diclofenac entirely in patients with active peptic ulcer disease 2
• For patients at risk of GI bleeding but without active ulceration, co-prescribe a proton pump inhibitor 3
• The standard 75 mg dose carries acceptable GI risk when used as a single dose 1

Renal Impairment

• Exercise extreme caution in patients with pre-existing kidney disease - even a single 100-200 mg dose of diclofenac can cause progression from subclinical acute kidney injury to chronic kidney disease 4
• Avoid diclofenac in patients with severe renal impairment (CrCl <10 mL/min) 2
• For patients with compromised renal function or taking nephrotoxic drugs, consider acetaminophen 1000 mg as an alternative 2
• The 75 mg dose is safer than higher doses (100-200 mg) in patients with any degree of renal compromise 4

Bleeding Disorders and Anticoagulation

• Diclofenac causes platelet inhibition and increases bleeding risk 3
• For patients on antiplatelet therapy (aspirin, clopidogrel), the single 75 mg dose poses minimal additional bleeding risk for this low-risk urological procedure 3
• Stent removal is considered a low-risk bleeding procedure, similar to diagnostic endoscopy with biopsy 3
• Continue aspirin if prescribed; do not discontinue for stent removal 3

Cardiovascular Disease

• Use the lowest effective dose (75 mg) for the shortest duration (single dose) to minimize cardiovascular risk 2
• The single-dose regimen for stent removal aligns with safety recommendations for patients with cardiovascular disease 2

Alternative Analgesic Options

If diclofenac is contraindicated:

• Acetaminophen 1000 mg orally 1 hour preprocedure (maximum 4000 mg/day) is the preferred alternative for patients with multiple contraindications to NSAIDs 2
• Ketorolac 30 mg IV has comparable efficacy to diclofenac but carries similar NSAID-related risks 5
• Intraurethral 2% lignocaine gel (25 mL) should be used in all patients regardless of systemic analgesic choice 1

Common Pitfalls to Avoid

• Do not use diclofenac in patients with rapidly deteriorating renal function - even subclinical AKI can progress to CKD with a single dose 4
• Do not exceed 75 mg for preprocedural dosing - higher doses (100-200 mg) significantly increase nephrotoxicity risk without proportional analgesic benefit in this setting 4, 1
• Do not combine diclofenac with other NSAIDs - this increases risk without additional benefit 2
• Do not give diclofenac to patients taking concomitant nephrotoxic drugs without careful risk-benefit assessment 2
• Do not use in patients with active peptic ulcer disease 2

Efficacy Data

The 75 mg oral dose provides:

• Significant pain reduction during the procedure (50% reduction in median VAS score) 1
• Extended analgesia lasting 24 hours with continued pain reduction at first void and 24-hour assessment 1
• Minimal adverse effects - incidence of epigastric pain, nausea, vomiting, and urinary retention comparable to placebo 1