Is it safe to administer diclofenac (nonsteroidal anti-inflammatory drug (NSAID)) injection to an elderly female patient?

Diclofenac Injection in Elderly Women: Strong Caution Required

Diclofenac injection should be used with extreme caution in elderly women and only after careful risk-benefit assessment, as the FDA explicitly warns that elderly patients are at greater risk for serious gastrointestinal events and cardiovascular complications with NSAIDs. 1

Critical Safety Concerns in the Elderly

Cardiovascular Risks

• NSAIDs, including diclofenac, carry an FDA black box warning for increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal 1
• This cardiovascular risk is particularly elevated in elderly patients who often have pre-existing cardiovascular disease or multiple risk factors 2
• The risk increases with duration of use, making even short-term injectable therapy concerning in high-risk elderly patients 1

Gastrointestinal Complications

• The FDA specifically states that elderly patients are at greater risk for serious gastrointestinal adverse events including bleeding, ulceration, and perforation, which can be fatal 1
• These events can occur at any time during use and without warning symptoms 1
• Advanced age (≥60 years) is an independent risk factor for upper gastrointestinal tract bleeding and perforation with NSAID use 2

Renal Toxicity

• Elderly patients have reduced renal function and medication clearance even in the absence of overt renal disease, increasing susceptibility to NSAID accumulation and toxicity 2
• NSAIDs should be prescribed with extreme caution in patients older than 60 years, particularly those with compromised fluid status or renal insufficiency 2
• Diclofenac can reduce the natriuretic effect of diuretics, which many elderly patients require 1

When Diclofenac Injection Might Be Considered

Acceptable Clinical Scenarios

• Acute severe pain requiring rapid onset analgesia (e.g., renal or biliary colic) where the benefit clearly outweighs risks and treatment duration will be very limited 3
• Situations where oral administration is not feasible and alternative analgesics are contraindicated or ineffective 3

Mandatory Precautions Before Administration

• Screen for cardiovascular disease history, including hypertension, prior MI, stroke, or heart failure 2, 1
• Assess for gastrointestinal risk factors: history of peptic ulcer disease, GI bleeding, concurrent corticosteroid or anticoagulant use 2
• Evaluate renal function and hydration status 2, 1
• Review all concurrent medications for potential interactions, particularly warfarin, ACE inhibitors, diuretics, lithium, and methotrexate 1
• Never administer if the patient is on anticoagulation therapy, as the combination significantly increases bleeding risk (3-6 fold increase) 2

Safer Alternative Approaches

First-Line Recommendations

• Topical diclofenac gel is a significantly safer alternative with reduced systemic absorption and lower cardiovascular and gastrointestinal risk 4, 5
• Topical NSAIDs show comparable efficacy to oral/injectable forms for localized musculoskeletal pain with minimal systemic side effects 2, 5

Other Preferred Options

• Acetaminophen (up to 3-4g daily) should be considered first-line for elderly patients, with superior safety profile and no cardiovascular, renal, or gastrointestinal toxicity 4
• For neuropathic pain components, gabapentin or duloxetine do not affect blood pressure or carry NSAID-related risks 4

If Systemic NSAID Required

• Use the lowest effective dose for the shortest possible duration 2
• Consider adding proton pump inhibitor prophylaxis for gastrointestinal protection 2
• Implement increased monitoring for adverse effects including renal function, blood pressure, and signs of GI bleeding 2

Absolute Contraindications

• Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery 1
• Active peptic ulcer disease or recent gastrointestinal bleeding 2
• Severe heart failure or recent myocardial infarction 2
• Concurrent therapeutic anticoagulation 2
• Severe renal impairment 2

Key Clinical Pitfall

The most common error is underestimating cumulative risk in elderly patients who appear "healthy" but have multiple subclinical risk factors (mild renal insufficiency, controlled hypertension, age-related cardiovascular changes). Even a single injection carries meaningful risk in this population, and the decision should never be made casually. 1