Diclofenac and misoprostol Side Effects
Please note - some side effects for Diclofenac and misoprostol may not be reported. Always consult your doctor or healthcare specialist for medical advice. You may also report side effects to the FDA.
Side Effects by Body System - for Healthcare Professionals
Applies to: oral tablet
Gastrointestinal (GI) side effects have been reported the most frequently. These have included abdominal pain (21%), diarrhea (19%), dyspepsia (14%), nausea (11%) and flatulence (9%). Diarrhea and constipation may occur early in the course of therapy, are self-limited and disappear within two to seven days. Other gastrointestinal effects include anorexia, appetite changes, constipation, dry mouth, dyspepsia, enteritis, esophageal ulceration, esophagitis, eructation, gastritis, gastroesophageal reflux, GI bleeding, GI neoplasm benign, glossitis, heartburn, hematemesis, hemorrhoids, intestinal perforation, peptic ulcer, stomatitis and ulcerative stomatitis, tenesmus, pseudomembranous colitis, colonic strictures, ileocolitis, and vomiting.
Gastrointestinal side effects, including diarrhea (up to 40%), abdominal pain (up to 20%), nausea (3.2%), flatulence, and dyspepsia, are commonly associated with misoprostol therapy.
In one safety review, gastrointestinal bleeding was reported in 0.16% and 0.17% of patients following short-term (duration not defined) and long-term (up to 58 weeks) treatment with diclofenac, respectively. Peptic ulceration occurred in 0.16 and 0.34% of patients, respectively. The manufacturer reports a higher incidence, 2 to 4%, of serious gastrointestinal events in patients treated with diclofenac for up to 1 year.
Colonic strictures, ulcerations, and bleeding associated with diclofenac use have been reported in the literature. Several authors have speculated that the enteric, or "delayed release", form of diclofenac may be at fault, as tablet fragments have been found at the site of the pathology.
Patients with a history of serious gastrointestinal events or alcohol abuse are at increased risk for severe gastrointestinal side effects. Diclofenac-misoprostol should be used with caution in these patients.
Elevations in serum transaminases three times normal values are reported in up to 2% of patients during the first 2 months of diclofenac therapy. Elevations eight times normal values occurred in 1% of patients over 2 to 6 months of therapy. In one review of 26 cases of diclofenac-induced hepatitis, the authors found a correlation between the cumulative diclofenac dose and severity of liver damage as well as the logarithm of the peak and mean transaminase levels. Elevations in serum transaminases are generally reversible upon cessation of diclofenac therapy.
Fatal cases of fulminant hepatitis during diclofenac therapy are reported in the literature. Autopsies in these cases revealed massive hepatic necrosis and cholestasis. Diclofenac-induced hepatitis may be a result of a hypersensitivity reaction in some cases. Three reported cases had features of autoimmune chronic active hepatitis, with accompanying positive ANA titers. Eosinophilia, maculopapular rash, fever, and lymphadenopathy have also been present in some cases.
Hepatic side effects have included elevations in serum transaminases in up to 15% of patients as well as rare cases of hepatitis, jaundice, and fatal fulminant hepatitis. Liver failure and pancreatitis have also been reported. Liver injury is most likely in older females in the first 6 months of use.
Diclofenac may impair the ability of the kidney to cope with low renal blood flow states due to inhibition of prostaglandin-dependent afferent arteriolar vasodilation. Renal function may be further compromised in patients with heart failure, hypovolemia, cirrhosis, nephrotic syndrome, or hypoalbuminemia. Additional risk factors for diclofenac-induced renal insufficiency are advanced age and concomitant use of diuretics or ACE inhibitors.
A case-control study suggested that patients who consumed 5000 or more pills containing NSAIDs during their lifetime may be at increased risk of end-stage renal disease.
Renal side effects have included cystitis, nephrotic syndrome, interstitial nephritis, renal papillary necrosis, acute renal failure, urinary frequency, nocturia, proteinuria, and hematuria.
Dermatologic side effects have included acne, alopecia, bruising, eczema, erythema multiforme, exfoliative dermatitis, pemphigoid reaction, photosensitivity, pruritus, pruritus ani, rash, skin ulceration, Stevens-Johnson, sweating increased, toxic epidermal necrolysis. In addition, severe pustular psoriasis has been reported.
Hematologic side effects have included agranulocytosis, anemia, aplastic anemia, coagulation time increased, ecchymosis, eosinophilia, epistaxis, hemolytic anemia, leukocytosis, leukopenia, lymphadenopathy, melena, pancytopenia, pulmonary embolism, purpura, rectal bleeding, thrombocythemia, and thrombocytopenia. Blood dyscrasias are usually reversible upon cessation of diclofenac, although rare fatalities are reported.
Hematologic abnormalities are uncommon during misoprostol therapy, but include thrombocytopenia purpura, anemia, abnormal differential, and increases in ESR.
Autoimmune hemolytic anemia and thrombocytopenia during diclofenac therapy have been associated with the development of autoantibodies as well as drug- or metabolite-dependent antibodies, implicating a drug hypersensitivity. Evidence of the dyscrasia may be preceded by other signs of hypersensitivity such as rash, pruritus, and fever. In one case, diclofenac-induced thrombocytopenic purpura was accompanied by renal and hepatic toxicity.
Agranulocytosis and aplastic anemia during diclofenac therapy are reported as well, and have resulted in patient death despite proper management.
A disproportionate amount of postoperative hemorrhage requiring operative intervention has been reported with the use of diclofenac when used for analgesia after adenotonsillectomy.
Musculoskeletal side effects have included arthralgia and myalgia.
A 44-year-old man with recurring knee pain treated himself with diclofenac 75 mg intramuscularly for 6 days followed by 75 mg orally three times a day for seven days. During the last three days of diclofenac treatment, he became anorexic and complained of nausea, epigastric pain and developed erythematous pruritic eruptions over his back, abdomen, chest, face and scalp. He denied use of other medications or any drug allergies. Serum LDH, SGOT, SGPT were all elevated. His muscle strength gradually decreased. Serum CPK levels peaked at 83,770 units/L 11 days following diclofenac cessation. The patient was diagnosed with erythema multiforme and rhabdomyolysis due to diclofenac. Six months following cessation of diclofenac, the patient was asymptomatic and strength was normal.
Hypersensitivity side effects have included anaphylactoid reactions, and anaphylaxis, angioedema, laryngeal or pharyngeal edema, and urticaria.
Metabolic side effects have included increases in alkaline phosphatase and BUN, dehydration, glycosuria, gout, hypercholesterolemia, hyperglycemia, hyperuricemia, hypoglycemia, hyponatremia, periorbital edema, porphyria, chills, and weight changes.
Aseptic meningitis was reported in a 42-year-old female following two weeks of therapy with diclofenac 50 mg three times a day. CSF eosinophilia was present in the absence of peripheral eosinophilia, a finding similar to that seen with other cases of NSAID-induced aseptic meningitis. The patient's symptoms spontaneously resolved over 48 hours following the discontinuation of diclofenac.
Nervous system side effects have included coma, convulsions, dizziness, drowsiness, headache, hyperesthesia, hypertonia, hypoesthesia, insomnia, meningitis, migraine, neuralgia, paresthesia, somnolence, tremor and vertigo.
Cardiovascular side effects have included arrhythmia, atrial fibrillation, congestive heart failure, hypertension, hypotension, increased CPK, increased LDH, myocardial infarction, palpitations, phlebitis, premature ventricular contractions, syncope, tachycardia, and vasculitis. In addition, blood pressure may be elevated by diclofenac which may have clinical relevance in patients with comorbid illnesses.
Nonsteroidal anti-inflammatory drugs (NSAIDs) may elevate blood pressure and increase the risk for the initiation of antihypertensive therapy. Furthermore, NSAIDs may antagonize the blood pressure lowering effect of antihypertensive medications in patients already being treated with antihypertensive drugs.
Psychiatric side effects of diclofenac include rare reports of depression, anxiety, irritability, nightmares, and psychotic reactions.
Other diclofenac side effects include tinnitus, blurred vision, taste disturbance, reversible hearing loss, dry eyes, scotoma, night blindness, and amblyopia. Diclofenac eye drops (0.1%) may cause transient stinging or burning.
A case of misoprostol-induced fever has been reported in the literature.
Postmenopausal bleeding may occur in patients treated with misoprostol. It is recommended that patients who develop postmenopausal bleeding undergo gynecological evaluation to rule out non-drug related pathology.
A 25-year-old female developed stress urinary incontinence after one month of misoprostol therapy. The patient was rechallenged with misoprostol with symptoms recurring after 7 days of therapy. Urodynamic studies revealed a deficiency in urethral resistance while on misoprostol.
Genitourinary side effects have included dysmenorrhea, dysuria, hematuria, intermenstrual bleeding, leukorrhea, menstrual disorder, menorrhagia, micturition frequency, nocturia, and vaginal hemorrhage. Also, impotence and perineal pain have been reported.
Ocular side effects have included amblyopia, blurred vision, conjunctivitis, diplopia, glaucoma, iritis, abnormal lacrimation, night blindness, and abnormal vision.
Respiratory side effects have included asthma, coughing, dyspnea, hyperventilation, pneumonia, and respiratory depression.Top
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