Is Voltaren (diclofenac) a suitable treatment option for a 60-year-old diabetic lady with knee pain?

Voltaren (Diclofenac) Is Not Recommended for a 60-Year-Old Diabetic Patient with Knee Pain

Oral diclofenac (Voltaren tablets) is not recommended for this 60-year-old diabetic lady with knee pain due to significant cardiovascular and renal risks that outweigh potential benefits. 1

Risks of Oral NSAIDs in Diabetic Patients

Oral NSAIDs, including diclofenac, present several significant concerns for diabetic patients:

• Cardiovascular risk: Diclofenac has been shown to increase the risk of cardiovascular events with a relative risk of 1.63 (95% CI: 1.12-2.37) compared to placebo 1
• Renal complications: NSAIDs can cause dose-dependent reduction in renal blood flow, which may precipitate overt renal decompensation, particularly in diabetic patients 2
• Gastrointestinal risk: Age ≥60 years is an independent risk factor for NSAID-induced GI complications 2

Better Treatment Options for This Patient

1. First-line options:

• Acetaminophen (up to 4g/day) - safer cardiovascular and renal profile 1
• Topical NSAIDs - specifically topical diclofenac gel provides effective pain relief with minimal systemic absorption 1, 3, 4

2. For neuropathic pain component (if present):

• Pregabalin or duloxetine are recommended as first-line treatments for diabetic neuropathic pain 1
• Gabapentin is an alternative option with good evidence 1

Treatment Algorithm for Knee Pain in Diabetic Patients

1. Assess pain type:

   • Mechanical/inflammatory pain: Start with topical NSAID (diclofenac gel)
   • Neuropathic pain features: Consider pregabalin or duloxetine 1

2. If topical treatment insufficient:

   • Add acetaminophen (≤4g/day) 1
   • Consider intra-articular corticosteroid injection for short-term relief 1

3. For persistent pain:

   • Physical therapy and appropriate orthoses
   • Consider referral for comprehensive diabetic foot evaluation 1

Important Considerations and Monitoring

• Diabetic neuropathy assessment: Up to 50% of diabetic peripheral neuropathy may be asymptomatic but increases risk 1
• Renal function: Monitor creatinine if any systemic analgesics are used
• Foot examination: All diabetic patients should have comprehensive foot evaluations at least annually 1

Why Topical Diclofenac Is Preferred Over Oral

Topical diclofenac has demonstrated:

• Similar efficacy to oral NSAIDs for localized knee pain 4, 5
• Significantly lower systemic absorption (95% less than oral administration) 3
• Similar safety profile in patients ≥65 years compared to younger patients 3
• Primary side effects limited to minor local skin reactions rather than systemic complications 4, 6

Remember that pain management in diabetic patients requires careful consideration of cardiovascular and renal risks. The evidence clearly shows that topical NSAIDs provide a much safer alternative to oral diclofenac tablets while still offering effective pain relief for knee osteoarthritis.