Is it okay to prescribe Voltaren (diclofenac) tablets to a 60-year-old lady with knee pain?

Prescribing Voltaren (Diclofenac) Tablets for a 60-Year-Old Lady with Knee Pain

Topical diclofenac is preferred over oral diclofenac tablets for this 60-year-old lady with knee pain due to significantly lower risk of serious gastrointestinal, cardiovascular, and renal adverse events while maintaining comparable efficacy. 1

Risk Assessment for Oral NSAIDs in This Patient

This 60-year-old patient is at increased risk for NSAID-related complications:

• Age ≥60 years is specifically identified as a risk factor for both gastrointestinal and renal toxicities 2
• Patients over 60 require special consideration for NSAID use due to:
  • Higher risk of GI bleeding and ulceration
  • Increased risk of renal impairment
  • Potential cardiovascular complications

Treatment Algorithm for Knee Pain in This Patient

First-line options (in order of preference):

1. Topical NSAIDs (including diclofenac gel) 2

   • Comparable efficacy to oral NSAIDs for knee OA 1
   • Significantly reduced systemic exposure
   • Lower risk of serious adverse events

2. Acetaminophen (up to 4g/day) 2

   • Though some studies question efficacy compared to NSAIDs 3
   • Still recommended as first-line by guidelines due to safety profile

Second-line options (if first-line inadequate):

1. Oral NSAIDs with gastroprotection 2
   • If using oral diclofenac, MUST prescribe with a proton pump inhibitor
   • Use lowest effective dose for shortest duration possible 4
   • Monitor for adverse effects (renal, GI, cardiovascular)

Evidence on Diclofenac Safety Concerns

Diclofenac specifically carries significant risks:

• Cardiovascular risk: Meta-analyses show diclofenac has a relative risk of 1.63 (95% CI 1.12-2.37) for vascular events compared to placebo 2
• GI risk: Carries FDA black box warning for serious GI adverse events 4
• Renal risk: Age >60 years is a specific risk factor for renal toxicity 2

Monitoring Requirements if Oral Diclofenac is Prescribed

If oral diclofenac is absolutely necessary despite risks:

• Baseline blood pressure, BUN, creatinine, liver function tests, CBC and fecal occult blood 2
• Repeat every 3 months to ensure lack of toxicity 2
• Discontinue if:
  • BUN or creatinine doubles
  • Hypertension develops or worsens
  • Liver function tests increase
  • GI symptoms develop 4

Common Pitfalls to Avoid

1. Duration error: Using oral NSAIDs for prolonged periods increases risk
2. Dosing error: Using higher than needed doses
3. Monitoring error: Failing to monitor for adverse effects
4. Gastroprotection error: Not prescribing PPI with oral NSAIDs in high-risk patients
5. Alternative consideration error: Not considering topical NSAIDs first

Conclusion

For this 60-year-old lady with knee pain, the evidence strongly supports using topical diclofenac over oral tablets. Topical formulations provide similar efficacy with significantly reduced systemic exposure and risk of serious adverse events 1, 5. If pain control is inadequate with topical NSAIDs, consider acetaminophen or other non-pharmacological approaches before resorting to oral NSAIDs.