Is it safe to use topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as diclofenac (generic name), before surgery in a typical adult patient without significant medical history, such as gastrointestinal disease, kidney disease, or bleeding disorders?

Topical NSAIDs Before Surgery

Topical NSAIDs should not be used before surgery for systemic pain management, as they lack evidence for efficacy in this context and are contraindicated in the perioperative setting. 1, 2

FDA Black Box Warning and Contraindications

The FDA explicitly contraindicates all NSAIDs, including topical formulations, for perioperative pain in the setting of coronary artery bypass graft (CABG) surgery. 2 NSAIDs may cause serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal, with this risk potentially occurring as early as the first weeks of treatment. 2

Topical NSAIDs are specifically not recommended for procedural pain management in critically ill adults undergoing surgery. 1 The Critical Care Medicine guidelines made a conditional recommendation against using topical NSAID gel for procedural pain management due to concerns about study quality and high acquisition costs. 1

Evidence for Systemic (Not Topical) NSAIDs in Perioperative Settings

While topical NSAIDs lack evidence for preoperative use, systemic NSAIDs have been studied:

Pre-emptive Systemic NSAIDs (Given Before Surgery, Not Continued After)

• Pre-emptive systemic NSAIDs probably decrease early acute postoperative pain by a small amount (mean difference -0.69 on 0-10 scale), though this does not reach the minimal clinically important difference of 1.5 points. 3
• Pre-emptive systemic NSAIDs may reduce 24-hour morphine consumption by approximately 5.62 mg, which does not meet the clinically important threshold of 10 mg reduction. 3
• Clinically significant adverse events from systemic NSAIDs administered before surgery are possibly under-reported, making it impossible to define with high-level evidence the safety of either preemptive or preventive NSAIDs. 1

Preventive Systemic NSAIDs (Given Before Surgery and Continued After)

• Preventive systemic NSAIDs may show little or no difference in early acute postoperative pain. 3
• Preventive systemic NSAIDs probably reduce 24-hour morphine consumption by approximately 1.93 mg, which is not clinically significant. 3

Critical Safety Concerns for All NSAIDs (Including Topical)

Avoid NSAIDs entirely in patients with:

• Recent myocardial infarction (increased risk of reinfarction and cardiovascular death beginning in the first week of treatment) 2
• Severe heart failure (two-fold increase in hospitalizations for heart failure) 2
• Advanced renal disease or creatinine clearance <50 mL/min 2
• History of peptic ulcer disease or gastrointestinal bleeding (greater than 10-fold increased risk) 2
• Known or suspected bacteremia, coagulopathy, or therapeutic anticoagulation 4

Use extreme caution in:

• Patients with cardiovascular disease risk factors (diclofenac shows RR 1.63 for vascular events vs. placebo) 1
• Elderly patients (at greater risk for serious gastrointestinal events) 2
• Patients taking corticosteroids, anticoagulants, SSRIs, or aspirin concurrently 2

Recommended Alternative Approach

For perioperative pain management, use systemic multimodal analgesia instead:

• Acetaminophen 1g IV every 6 hours (maximum 4g/24h) as the foundation 5
• Consider systemic NSAIDs (oral or IV, not topical) only if no contraindications exist, given intraoperatively or postoperatively rather than preoperatively 1, 5
• Reserve opioids for breakthrough pain not controlled by non-opioid regimen 1, 5

Common Pitfalls to Avoid

• Do not assume topical NSAIDs have the same efficacy as systemic NSAIDs - topical formulations minimize systemic absorption but also reduce analgesic efficacy for surgical pain. 6
• Do not use NSAIDs in colorectal surgery with intestinal anastomoses due to increased risk of anastomotic dehiscence and impaired healing. 5, 1
• Do not combine NSAIDs with COX-2 inhibitors as this significantly increases risk of gastrointestinal bleeding, acute kidney injury, and cardiovascular events. 5, 1
• Do not rely on topical NSAIDs for systemic pain control - one small study showed topical valdecoxib reduced chest tube removal pain, but guidelines recommend against its use due to quality concerns and cost. 1