II. Medications: Diclofenac

  1. Diclofenac Solution (Pennsaid 1.5%)
  2. Diclofenac Gel (Voltaren Gel 1.5%)
  3. Diclofenac Patch (Flector Patch)

III. Medications: Other NSAIDs

  1. Pharmacy may compound other NSAIDs (e.g. Ketoprofen, Piroxicam, Ibuprofen)

IV. Dosing: Diclofenac 1% gel applied to affected joints

  1. Will be OTC without a prescription in 2020
  2. Measure gel on a dosing card and massage into affected area
    1. Two grams is 2.25 inches (6 cm) long when squeezed from tube
    2. Four grams is 4.5 inches (11.5 cm) long when squeezed frin tube
  3. Overall maximum: 32 grams/day over all affected joints
  4. Elbow, hand or wrist: 2 grams applied up to 4 times daily (maximum 8 grams/day/joint)
  5. Knee, ankle or foot: 4 grams applied up to 4 times daily (maximum 16 grams/day/joint)
  6. Not recommended for larger joints (hip, Shoulder), as likely to be ineffective
  7. May use for up to 7 days

V. Precautions

  1. Despite low absorption (<10%), cardiovascular and renal risks may still pertain to Topical NSAIDs
  2. Do not combine with other topicals or other NSAID forms
  3. Do not apply heat to application site
  4. Avoid washing area or showering for at least one hour after application
  5. Limit Topical NSAID to the shortest duration needed

VI. Pharmacokinetics

  1. Systemic absorption <10% (gel may be 6%)

VII. Adverse effects

  1. Local skin reactions (Dry Skin or local irritation)
  2. Besides local reactions, systemic adverse event rate is very low compared with oral NSAIDs
    1. Klinge (2013) Phys Sportsmed 41(2): 64-74 +PMID:23703519 [PubMed]

VIII. Efficacy

  1. Knee Osteoarthritis pain relief was equivalent for Topical Diclofenac as for oral Diclofenac
    1. However, topical caused only local skin irritation, and oral Diclofenac had gastrointestinal adverse effects
    2. Tugwell (2004) J Rheumatol 31(10): 2002-12 +PMID:15468367 [PubMed]
  2. Acute musculoskeletal pain reduced by >50% with Topical Steroid (Number Needed to Treat 1.8)
    1. Derry (2015) Cochrane Database Syst Rev (6):CD007402 +PMID:26068955 [PubMed]

IX. Contraindications

  1. Absolute
    1. CABG history
    2. Asthma or aspirin Hypersensitivity
    3. Advanced renal disease
  2. Relative (use with caution in this group)
    1. Known cardiovascular disease
    2. Known Peptic Ulcer Disease (however topical Diclofenac did not appear to increase ulcer risk)
    3. Hypertension (however topical Diclofenac did not appear to increase Blood Pressure)
    4. Hepatic insufficiency
    5. Advanced Chronic Kidney Disease
    6. Congestive Heart Failure or other edematous condition

X. References

  1. (2016) Presc Lett 23(1): 2
  2. DeLaney in Herbert (2017) EM:Rap 17(11): 11-2

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Cost: Medications

pennsaid (on 5/18/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
PENNSAID 2% PUMP Generic $13.39 per gram