How many hours before surgery should diclofenac be discontinued, particularly in patients with high bleeding risk, impaired renal function, or cardiovascular disease?

Diclofenac Discontinuation Before Surgery

Diclofenac should be stopped 24 hours (1 day) before surgery for most procedures, though patients with high bleeding risk, impaired renal function, or cardiovascular disease may require extended discontinuation up to 5 days for major surgery or neuraxial anesthesia.

Standard Discontinuation Timeline

Low-to-Moderate Bleeding Risk Procedures

• Stop diclofenac 24 hours (1 day) before surgery for procedures such as arthroscopy, cutaneous biopsies, colonoscopy with biopsy, or minor dental work 1
• This single-day interruption allows adequate clearance of the NSAID effect while minimizing the period without anti-inflammatory coverage 1

High Bleeding Risk Procedures

• Stop diclofenac 5 days before major elective surgery, particularly for orthopedic procedures, neuraxial blockade (spinal/epidural anesthesia), or intracranial surgery 2
• Major surgeries requiring extended discontinuation include joint replacement, major cancer surgery, abdominal hysterectomy, and procedures in closed spaces like intracranial or spinal surgery 2, 3

Special Population Considerations

Patients with Renal Dysfunction

• Extend discontinuation to 5 days before surgery in patients with impaired renal function undergoing major procedures 2
• Renal insufficiency prolongs NSAID elimination and increases both bleeding and renal adverse event risk, necessitating longer drug-free intervals 4
• Even in patients with pre-existing renal insufficiency, diclofenac can be used perioperatively, but requires careful timing and monitoring 4

Patients on Anticoagulation

• Stop diclofenac at least 24 hours before surgery in patients receiving concomitant anticoagulants, as NSAIDs significantly increase bleeding risk when combined with anticoagulants or antiplatelet agents 1, 4
• The combination of diclofenac with anticoagulants creates additive bleeding risk that must be managed by ensuring complete NSAID clearance before high-risk procedures 1
• In a large safety study, 62% of patients received concomitant anticoagulants with parenteral diclofenac postoperatively without excessive bleeding complications, but preoperative discontinuation remains critical 4

Cardiovascular Disease Patients

• For patients with coronary stents, postpone elective surgery for at least 4-6 weeks after bare metal stent implantation and 6 months after drug-eluting stent implantation 2
• Continue aspirin during the perioperative period except for closed-space surgery (intracranial, spinal), but stop diclofenac according to standard timelines 2
• In patients at low cardiovascular risk having major surgery, aspirin should be discontinued 5 days before the procedure, and diclofenac should follow the same timeline 2

Postoperative Resumption

Timing of Restart

• Resume diclofenac 24 hours after low bleeding risk procedures once adequate hemostasis is established 3, 5
• Wait 48-72 hours after high bleeding risk procedures before restarting diclofenac to ensure complete hemostatic control 3

Safety Considerations

• Diclofenac has been safely administered as early as the immediate postoperative period in large studies including elderly and renally insufficient patients, but only after hemostasis is confirmed 4
• The decision to resume should account for ongoing bleeding risk, renal function, and concomitant anticoagulant use 4

Critical Pitfalls to Avoid

Common Errors

• Failing to account for drug interactions: NSAIDs combined with anticoagulants or antiplatelet agents dramatically increase bleeding risk and may require longer discontinuation periods 1
• Inadequate communication: Surgical teams must directly verify NSAID discontinuation timing rather than relying solely on medical consultants who may underestimate perioperative bleeding risks specific to surgery 1
• Ignoring renal function: Standard 24-hour discontinuation is insufficient in patients with renal impairment undergoing major procedures 2

Neuraxial Anesthesia Warning

• Never proceed with spinal or epidural anesthesia without confirming 5-day diclofenac discontinuation in high-risk patients, as epidural bleeding can cause devastating lower limb paralysis 2, 6

Procedure-Specific Adjustments

• For minimal bleeding risk procedures (minor dermatologic procedures, cataract surgery, pacemaker implantation), diclofenac may be continued without interruption 3
• For procedures requiring only local hemostasis (simple dental extractions), 24-hour discontinuation is typically sufficient 5