Drugs you may need to avoid with a diverticulitis flare-up include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) used for pain and inflammation like ibuprofen (Advil, Motrin), naproxen (Aleve) or diclofenac.
• Opioid analgesics (pain medicines) such as codeine, hydrocodone, tramadol, fentanyl, hydromorphone or oxycodone.
• Corticosteroid (“steroid”) medicines like prednisone, methylprednisolone or dexamethasone.
• Menopausal hormone therapy (MHT) such as estrogens and the combined use of estrogen plus progestin.
• Anticoagulants such as warfarin and anti-thrombotic drugs such as aspirin and clopidogrel (Plavix) used to help prevent blood clots.
• Excessive alcohol use or alcoholism is also a risk factor for diverticulitis.

Drugs that can cause constipation may also worsen diverticulitis or bring on a flare-up. Many medicines can lead to constipation, including opioids, certain antihistamines, some calcium channel blockers and anticholinergic medications.

Have your healthcare provider or pharmacist review your medications for a constipation side effect, but do not change or stop any medications without your doctor's okay first.

In some cases, patients with ongoing stomach pain due to diverticulitis may be prescribed a low-dose tricyclic antidepressant (TCA) for pain control. Some TCA's have a strong anticholinergic effect, which may worsen constipation. Speak with your doctor about the risk of constipation with these treatments.

If you experience constipation with diverticulitis, or have a history of diverticulitis, contact your healthcare provider right away who can recommend an appropriate and safe laxative for your condition.

If you have a history of diverticulitis, you should discuss all drug treatment and alcohol use with your doctor. In addition, do not stop any treatment without first speaking with your healthcare provider, who can weigh the risk versus benefit of treatments for your conditions.

Overview

NSAIDs

NSAIDs are a large group of medicines used to relieve inflammation, pain and lower fever. NSAIDS are commonly used to treat conditions like headaches, tooth pain, arthritis, muscle sprains, gout and period pain. Many options are available both over-the-counter (OTC) and with a prescription.

Common NSAID examples include:

• Aspirin (Ecotrin, Miniprin, generics)
• Ibuprofen (Motrin, Motrin IB)
• Naproxen (Aleve, Naprosyn)
• Celecoxib (Celebrex)
• Diclofenac (Cataflam, Zipsor)

Related: List of NSAIDs (in more detail)

Patients with a history of diverticulitis should avoid regular use (2 or more times per week) of NSAID drugs. Regular use of NSAIDs may increase the risk for diverticulitis, bleeding or bowel perforation (a tear in the intestine which requires surgery).

In some cases, your healthcare provider may recommend you avoid NSAIDs as much as possible or always, so check with them for advice. Usually acetaminophen (Tylenol) can be used safely for pain control in patients with diverticulitis. Be sure to follow dosing instructions to avoid an excessive dose that can cause liver toxicity.

The American Gastroenterological Association (AGA) clinical practice update states that NSAID use should be avoided with the exception of aspirin prescribed for secondary prevention of heart disease. In some people, aspirin may be prescribed in low doses to lower the risks of having a heart attack or a stroke caused by a blood clot.

The AGA update also states that use of NSAIDs increases the risk of diverticulitis, with the risk greater for non-aspirin NSAIDs (examples, ibuprofen, naproxen, celecoxib) than for aspirin.

A meta-analysis is a type of statistical study used to combine the results of multiple clinical trials to answer a related research question.

• A meta-analysis of 23 individual studies demonstrated an increase in the odds of perforation and abscess formation (Odd Ratio [OR ]1.46-10.30) and bleeding (2.01-12.60) with use of nonsteroidal anti-inflammatory drugs (NSAIDs) in people with diverticular disease.
• Pooled data also showed significantly increased odds of perforation and abscess formation with NSAIDs (OR = 2.49).
• The odds ratio (OR) is the ratio of odds of an event in one group (for example: those taking NSAIDs) versus the odds of the event in the other group (those not taking NSAIDs).

Opioids

Opioids, which may also be called narcotic analgesics, are a large group of drugs used to treat acute and long-term pain. They can be given by mouth, as injections, or by patch (skin absorption). They should be used for more moderate-to-severe pain when non-opioid pain treatments, like acetaminophen (Tylenol) are not adequate or appropriate.

Studies have shown that opioids can increase the risk of diverticulitis and complications, including bowel perforation. Opioids can also be associated with severe constipation which is known to worsen diverticulitis.

Common opioid examples include:

• Codeine
• Fentanyl (Actiq, Lazanda, Fentora, Subsys)
• Hydrocodone (Hysingla ER)
• Oxycodone (Oxaydo, Oxycontin, Roxicodone, RoxyBond, Xtampza ER)
• Tramadol (ConZip, Qdolo)

Related: List of Opioids / Narcotic Analgesics (in more detail)

In a large study, researchers looked at the outcomes of over 154,000 patients with diverticulitis. Data between 2008 and 2014 was extracted from the National Inpatient Sample (NIS) database. Over 151,000 non-opioid users with diverticulitis and over 2,900 patients with diverticulitis and active opioid use were hospitalized in the U.S. during this timeframe.

• The study showed that opioid users had a significantly higher (p <0.01) odds ratio (OR) for bleeding (2.364 [1.766-3.165]), sepsis (1.806 [1.447-2.252]), and obstruction (1.55 [1.22-1.97]) when compared to non-opioid users.
• Opioid users also had longer lengths of stay, higher total hospital charges and a higher risk of hospital readmission within 30 days.
• Non-opioid users had statistically higher rates of perforation (0.7% versus 0.5%) with OR of 0.476 (0.26-0.89) and fistula formation (0.7% versus 0.3%) with OR of 0.832 (0.746-0.929).

Patients hospitalized for acute diverticulitis who had used opioids had a similar rate of death compared to those who did not use opioids (0.5% versus 0.5%).

Learn more: Which drugs cause opioid-induced constipation?

Corticosteroids

According to the AGA Clinical Practice Update, corticosteroid use is a risk factor for diverticulitis and may contribute to complications including bowel perforation and death. Corticosteroids have also been shown to be a potential risk factor for death in patients with perforated diverticular disease.

Corticosteroids, sometime called "steroids", are commonly given as a pill, as an oral inhalation, applied topically or as an injection. They are used to treat many disorders, including allergic symptoms, asthma, ulcerative colitis, Crohn’s disease, arthritis, and psoriasis. They may also be used in cancer treatment and organ transplants to help suppress the immune system and lower inflammation.

Common corticosteroid examples include:

• Prednisone
• Methylprednisolone
• Triamcinolone
• Dexamethasone
• Budesonide

Related: List of Glucocorticoids / Corticosteroids (in more detail)

Patients with a suppressed (lowered) immune system (which can happen with corticosteroid use) and uncomplicated diverticulitis may be at a greater risk for progressing to complicated diverticulitis or sepsis (severe inflammation in the body due to an infection that may be life-threatening). These patients typically require antibiotic treatment and / or a surgical intervention.

A cohort study based on medical databases in Denmark from 2005 to 2013 included 4640 patients with perforated diverticular disease (ruptured bowel). Of these, 3743 (80.7%) patients had not used corticosteroids in the year before hospital admission, while 725 (15.6%) had used systemic corticosteroid treatment. The remaining 172 patients had been exposed to either inhaled or intestinal acting corticosteroid therapy.

• The risk of death (mortality) in patients not using corticosteroids was 4.4% seven days after admission and 15.6% one year later.
• This risk was doubled for patients who filled their last corticosteroid prescription during the 90 days before admission. Mortality risks ranging from 14.2% after 7 days to 47.6% after 1 year.
• One year mortality risk was even higher at 52.5% for patients filling a corticosteroid prescription for the first time during the 90 days before admission.

Menopausal hormone therapy (MHT)

Menopausal hormone therapy (MHT) with estrogen or the combination of estrogen and progestin has been shown to be associated with increased risk of diverticulitis in clinical studies, but the risk was not associated with drug doses or how long the medicine was taken (duration).

In the observational Nurses Health Study, researchers found an increased risk of diverticulitis among people currently using MHT and people who had used it in the past, compared to people who had never used it.

This association was observed for users of estrogen only and combined estrogen plus progestin users. Over 24 years encompassing 1,297,165 person-years of follow-up, the researchers documented 5,425 incident cases of diverticulitis.

The association between MHT and diverticulitis was not modified by age, body mass index, past oral contraceptive use, or amount of fiber intake (all P-interaction >0.11).

Researchers also found a significant association between people who had used MHT and the occurrence of uncomplicated diverticulosis (OR 1.31; 95% CI 1.23–1.39).

The authors note that the effect of MHT should be considered by healthcare providers and patients considering MHT. especially in those at increased risk for diverticulitis. Further studies are needed to determine why hormonal therapy may increase the risk for diverticulitis, but some theories include altered gut microbiota or increased inflammatory risk.

Related: Medications for Postmenopausal Symptoms

Anticoagulants / Antiplatelets

• Anticoagulants such as warfarin (Jantoven) and anti-thrombotic drugs such as aspirin and clopidogrel (Plavix) are used to help prevent blood clots from forming.
• These drugs were shown to increase the risk of diverticular bleeding in a case control study of patients admitted to a hospital with diverticulitis vs. those with diverticular bleeding.

Calcium channel blockers

Calcium channel blockers are used to help lower blood pressure, treat certain types of angina (chest pain) or for abnormal heart rhythms.

Common calcium channel blocker examples include:

• amlodipine (Norvasc)
• diltiazem (Cardizem, Cartia XT)
• verapamil (Verelan)

While not listed in the 2021 AGA Clinical Practice Update, a meta-analysis has shown an increased odds (OR = 2.50) of diverticular bleeding from calcium channel blockers. Most studies in this meta-analysis did not describe the dose or how long the medication was used and did not systematically describe the severity of diverticular complications.

A case control study also found a significant association of calcium channel blockers with diverticular bleeding.

Calcium channel blockers can also cause constipation as a side effect, especially agents like verapamil or diltiazem, which may worsen symptoms.

Related: List of Calcium Channel Blockers (in more detail)

What is diverticulitis?

Diverticulitis is an inflammation of pouches in the wall of the large intestine called diverticula. In some cases, infections may occur.

• Diverticula are often seen in the last part of the large intestine (known as the sigmoid colon), and are often diagnosed during a routine screening colonoscopy for colon cancer. They may also be detected during a CT scan of your abdomen or a barium enema.
• The presence of diverticula without inflammation or infection is known as diverticulosis, and most people are not aware they have them until they are seen during a colonoscopy.

Not everyone with diverticulosis will get diverticulitis. Many people live their entire lives without any problems from diverticulosis. The presence of diverticula is common in the Western world, but the exact causes have not been proven.

It is theorized that a diet low in fiber, high in red meat, obesity or overweight, smoking, lack of physical activity and genetics may all contribute to a higher risk for disease occurrence.

The occurrence of diverticulosis increases with age. It estimated that over half of people over the age of 60 years in the U.S. may have diverticula.

In a smaller subset of people, the diverticula may become inflamed or infected and can lead to diverticulitis. This can cause pain and tenderness in the left lower section of your stomach area (lower left quadrant), along with cramping fever, chills, nausea, vomiting, constipation, diarrhea, or bleeding.

Diagnosis is usually done with a clinical physical examination, blood and urine testing and an imaging test of your abdomen and pelvis called a CT scan. Contact your doctor right away or get emergency care if you develop symptoms of diverticulitis.

• Mild diverticulitis is usually treated with a clear liquid diet for a few days, rest, and possibly antibiotics. Today, experts believe more mild or uncomplicated diverticulitis may not need antibiotic treatment.
• More severe symptoms or signs of infection may be treated with oral antibiotic treatment on an outpatient basis. Augmentin or a combination of Cipro / Flagyl are often used for treatment for 5 to 10 days.
• Severe diverticulitis, especially with pus or an abscess pocket, usually needs antibiotic treatment in the hospital. Surgery called a colectomy may be needed for severe or frequent diverticulitis which may involve strictures, perforations or fistulas.
• If you are immunocompromised, you will probably need antibiotic treatment even if you have uncomplicated or mild diverticulitis.

What are the symptoms of diverticulitis?

Symptoms can vary among patients. The most common symptoms include:

• Pain in the lower left side of your abdomen (stomach area) - tenderness or pressure
• Fever
• Chills
• Nausea or vomiting
• Constipation
• Diarrhea
• Need to urinate frequently
• Blood in your stool
• Bloating
• Gas

What are the risk factors for diverticulitis?

Diverticulitis is more common among people over the age 50. Other factors that may increase the risk of diverticulitis include:

• Obese or overweight
• Smoking
• A diet without adequate fiber intake
• Red meat
• Heavy alcohol use
• Lack of exercise
• Low vitamin D levels
• Genetics

It’s not always known what causes a flare-up of diverticulitis. Diet, lifestyle, medication use and genetics can all contribute to symptoms.

Is constipation a risk factor for diverticulitis?

Constipation may be a risk factor for complicated diverticulitis and may be a symptom of the disease, as well. Constipation can lead to pressure in the bowel and may weaken areas of an inflamed diverticulum, leading to strictures, bleeding or a perforation.

Drugs that may cause constipation, such as opioids, sedating antihistamines, some antidepressants, drugs for bladder control, or other drugs with strong anticholinergic properties may cause or worsen constipation.

Other medications that may contribute to constipation include iron, bismuth (found in Pepto-Bismol), calcium channel blockers, other psychotropic drugs and vitamin D intoxication.

Related: Anticholinergic Drugs to Avoid in the Elderly

Do I need antibiotics for diverticulitis?

Antibiotics may not always be needed for a mild flare-up of uncomplicated diverticulitis, but you should contact your healthcare provider right away, or go to the emergency room for a diagnosis if you are having worrisome symptoms.

Pain with diverticulitis typically occurs in the lower left side of the abdomen area. In many cases, mild symptoms can be treated with a clear liquid diet only for several days, followed by a low-fiber diet as tolerated. As symptoms start to improve, the diet can be advanced to include more fiber from fruits, vegetables, whole grains and legumes like beans or lentils.

If you have more severe symptoms, signs of infections, are immunocompromised, are older or have other medical conditions, you may need to be treated with antibiotics.

What long-term diet changes may help diverticulitis?

After recovering from a diverticulitis flare-up, most people are advised to slowly increase fiber intake to help soften stools and reduce the risk of future problems. Discuss with your doctor if including a daily fiber supplement like Metamucil or FiberCon is appropriate for you.

Avoiding red meat, or adhering to a vegetarian diet, and including vigorous physical activity may also decrease the risk of a flare-up. Obesity or overweight is also a risk factor for diverticulitis, so speak with your doctor and dietician about a possible weight loss plan.

In the past, many people with diverticulosis or diverticulitis were advised to avoid eating nuts, corn, popcorn, and fruits with small seeds (for example, strawberries, blueberries or kiwi fruit), but research shows that these foods are not associated with an increased risk of diverticulitis.

Excessive alcohol intake and alcoholism, but not alcohol consumption by itself, increases the risk of diverticulitis. It has been estimated that excessive consumption of alcohol may raise the risk of diverticulitis by 2 to 3 times as compared to the general population.

In one retrospective case-control study, alcohol use (defined as more than 2 drinks/day for males and more than 1 drink/day for females) was not found to be significantly associated with either diverticular bleeding or re-bleeding in the diverticulosis (case) group as compared to the diverticulitis (control) group.

Discuss the use of alcohol with your healthcare provider to determine if it may increase your risk for complications. If alcohol leads to a flare-up or worsens your symptoms, you may need to avoid it altogether

Bottom Line

• Medicines like nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, opioids used for pain, corticosteroids ("steroids") and menopausal hormonal therapy may worsen diverticulitis symptoms.
• Some studies have also shown an increased risk of diverticular bleeding from calcium channel blockers and blood thinner or anti-clotting agents.
• In some cases, constipation can worsen diverticulitis or bring on a flare-up. Speak with your healthcare provider about ways to prevent and treat constipation, like increasing fiber intake, staying hydrated, using a fiber supplement, stool softener or laxative, and avoiding medicines that cause constipation.

This is not all the information you need to know about diverticulitis, it's treatment or risk factors for safe and effective use. This information does not take the place of your doctor’s directions. Lists may not be complete or comprehensive. Review disease and drug information and discuss this information with your doctor or other health care provider.

References

• Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021 Feb;160(3):906-911.e1. doi: 10.1053/j.gastro.2020.09.059
• Hall J, Hardiman K, Lee S, et al; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum. 2020 Jun;63(6):728-747. doi: 10.1097/DCR.0000000000001679
• Diverticular Disease Expanded Information. American Society of Colon and Rectal Surgeons. 2020. Accessed August 27, 2024 at https://fascrs.org/patients/diseases-and-conditions/a-z/diverticular-disease-expanded-version
• Broersen LHA, Horváth-Puhó E, Pereira AM, et al. Corticosteroid use and mortality risk in patients with perforated colonic diverticular disease: a population-based cohort study. BMJ Open Gastroenterol. 2017 Apr 6;4(1):e000136. doi: 10.1136/bmjgast-2017-000136
• Gravante G, Yahia S. Medical influences, surgical outcomes: role of common medications on the risk of perforation from untreated diverticular disease. World J Gastroenterol. 2013 Sep 28;19(36):5947-52. doi: 10.3748/wjg.v19.i36.5947
• Kvasnovsky CL, Papagrigoriadis S, Bjarnason I. Increased diverticular complications with nonsteriodal anti-inflammatory drugs and other medications: a systematic review and meta-analysis. Colorectal Dis. 2014 Jun;16(6):O189-96. doi: 10.1111/codi.12516
• Shaikh A, Khrais A, Le A, Kaye AJ, Ahlawat S. Pre-existing Opioid Use Worsens Outcomes in Patients With Diverticulitis. Cureus. 2023 Feb 4;15(2):e34624. doi: 10.7759/cureus.34624
• Jovani M, Ma W, Joshi AD, Liu PH, Nguyen LH, et al. Menopausal Hormone Therapy and Risk of Diverticulitis. Am J Gastroenterol. 2019 Feb;114(2):315-321. doi: 10.14309/ajg.0000000000000054
• Bolkenstein HE, van de Wall BJM, Consten ECJ, et al. Risk factors for complicated diverticulitis: systematic review and meta-analysis. Int J Colorectal Dis. 2017 Oct;32(10):1375-1383. doi: 10.1007/s00384-017-2872-y
• McKeever RG, Patel P, Hamilton RJ. Calcium Channel Blockers. [Updated 2024 Feb 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482473/
• Estrada Ferrer O, Ruiz Edo N, Hidalgo Grau LA, et al.. Selective non-antibiotic treatment in sigmoid diverticulitis: is it time to change the traditional approach? Tech Coloproctol. 2016 May;20(5):309-315. doi: 10.1007/s10151-016-1464-0
• Carr S, Velasco AL. Colon Diverticulitis. [Updated 2024 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541110/
• Chabok A, Påhlman L, Hjern F, et al AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012 Apr;99(4):532-9. doi: 10.1002/bjs.8688
• Daniels L, Ünlü Ç, de Korte N, et al; Dutch Diverticular Disease (3D) Collaborative Study Group. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017 Jan;104(1):52-61. doi: 10.1002/bjs.10309
• Jalil AA, Gorski R, Jalil SA, et al. Factors associated with diverticular bleeding and re-bleeding: A United States hospital study. North Clin Istanb. 2018 Sep 5;6(3):248-253. doi: 10.14744/nci.2018.23540. PMID: 31650111; PMCID: PMC6790935.
• Kaplan RC, Heckbert SR, Koepsell TD, et al. Use of calcium channel blockers and risk of hospitalized gastrointestinal tract bleeding. Arch Intern Med 2000;160:1849–55. doi: 10.1001/archinte.160.12.1849
• Crowe FL, Appleby PN, Allen NE, et al.. Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians. BMJ. 2011 Jul 19;343:d4131. doi: 10.1136/bmj.d4131

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