Should I separate Rofinac (Diclofenac) from Paracetamol (Acetaminophen)?

Diclofenac and Paracetamol: Should They Be Separated?

No, you do not need to separate Rofinac (diclofenac) from paracetamol (acetaminophen) as they have no significant drug interactions and can be safely used together. According to the 2020 anaesthesia guidelines, both diclofenac and paracetamol are listed as having "no significant interaction" with common antiviral medications and with each other 1.

Evidence for Combined Use

The combination of diclofenac and paracetamol is well-supported by clinical evidence:

• According to the 2020 anaesthesia guidelines, both medications are considered safe to use together, with no reported significant drug interactions between them 1.
• The drug interaction table in the guidelines specifically shows that both paracetamol and diclofenac have "no effect" (marked as "!d") when used with various medications, indicating their safety profile 1.

Benefits of Combination Therapy

Using diclofenac and paracetamol together offers several advantages:

• Additive Analgesic Effect: Research shows that combining these medications provides better pain control than either medication alone 2.
• Dose Reduction: Combination therapy allows for lower doses of each medication while maintaining effective analgesia, potentially reducing side effects 3.
• Different Mechanisms: Diclofenac (NSAID) and paracetamol work through different mechanisms, providing complementary pain relief.

Clinical Considerations

When using this combination:

1. Dosing:

   • For adults, standard dosing applies (diclofenac 50mg 2-3 times daily, paracetamol 500-1000mg 4-6 times daily, not exceeding 4g/day)
   • For children, diclofenac 1mg/kg combined with paracetamol 15mg/kg achieves equivalent analgesia to paracetamol 30mg/kg alone 3

2. Efficacy:

   • Studies show that the combination provides superior pain control compared to either medication alone 2, 4
   • A fixed-dose combination of diclofenac and paracetamol has demonstrated significant reduction in pain scores starting from 15 minutes after administration 4

3. Safety Profile:

   • No increased risk of adverse effects has been reported when these medications are used together at appropriate doses
   • The 2020 guidelines specifically note that both medications have "!d" (no significant interaction) status 1

Potential Pitfalls and Precautions

While the combination is generally safe, be aware of:

• Individual Contraindications: Each medication has its own contraindications that still apply when used in combination:

  • Diclofenac: Avoid in patients with severe heart failure, history of GI bleeding, renal impairment
  • Paracetamol: Use with caution in patients with liver disease, avoid exceeding maximum daily dose

• COVID-19 Considerations: The 2020 anaesthesia guidelines note that NSAIDs may be associated with worsening symptoms during respiratory virus infections, though there is no definitive evidence linking NSAID use to aggravation of SARS-CoV-2 infection 1. As a precaution, NSAIDs should be avoided in patients with established or strongly suspected SARS-CoV-2 infection.

• Cardiovascular Risk: Long-term use of NSAIDs including diclofenac carries cardiovascular risks, particularly in patients with pre-existing cardiovascular disease 1. Use the lowest effective dose for the shortest duration.

Conclusion

The evidence clearly supports that diclofenac (Rofinac) and paracetamol can be safely used together. Their combination provides enhanced pain relief through complementary mechanisms of action without significant drug interactions. This combination is particularly useful in managing moderate to severe pain while potentially reducing the need for opioid analgesics.