Does Voltaren (diclofenac) ointment increase blood pressure (BP)?

Voltaren (Diclofenac) Ointment and Blood Pressure Effects

Yes, Voltaren (diclofenac) ointment can increase blood pressure, though the effect is typically less pronounced than with oral NSAIDs. 1

Mechanism and Risk Level

Diclofenac, like other nonsteroidal anti-inflammatory drugs (NSAIDs), can affect blood pressure through several mechanisms:

• Inhibition of prostaglandin synthesis, which normally promotes vasodilation and sodium excretion 2
• Antagonizing the effects of antihypertensive medications, particularly RAAS inhibitors and beta blockers 1
• Promoting sodium and water retention 1

The 2020 International Society of Hypertension guidelines specifically list NSAIDs, including diclofenac, as medications that can exacerbate hypertension, noting they can cause "no difference or an increase of up to 3/1 mm Hg with celecoxib" and "3/1 mm Hg increase with nonselective NSAIDs" like diclofenac 1.

Topical vs. Oral Administration

While most research focuses on oral NSAIDs, topical formulations like Voltaren ointment generally have:

• Lower systemic absorption
• Reduced risk of cardiovascular side effects
• Less impact on blood pressure than oral formulations

However, some systemic absorption still occurs, particularly with:

• Regular, extensive application
• Application to large surface areas
• Use on broken or inflamed skin
• Long-term use

Patient Risk Stratification

The blood pressure effect of topical diclofenac is more significant in certain populations:

• Elderly patients 2
• Patients with pre-existing hypertension 2
• Patients on antihypertensive medications 2
• Salt-sensitive hypertensive patients 3
• Patients with kidney disease 1
• Patients with heart failure 1

Clinical Recommendations

1. For patients with cardiovascular disease or multiple risk factors:

   • Consider alternative pain management strategies when possible
   • Use the lowest effective dose for the shortest duration
   • Monitor blood pressure regularly, especially during the first few weeks of treatment

2. For patients on antihypertensive medications:

   • Be aware that NSAIDs can antagonize the effects of RAAS inhibitors and beta blockers 1
   • Consider more frequent BP monitoring when initiating Voltaren ointment

3. For patients with heart failure:

   • Use with caution as NSAIDs can promote sodium and water retention 1
   • Consider alternative pain management options when possible

Monitoring Recommendations

• Check blood pressure within 1-2 weeks of initiating treatment in high-risk patients
• For long-term users, incorporate regular BP monitoring into follow-up visits
• Be vigilant for signs of fluid retention or worsening hypertension

Alternative Options

For patients with high cardiovascular risk who need topical pain relief:

• Lidocaine patches or creams
• Capsaicin
• Heat or cold therapy
• Physical therapy modalities

Remember that even topical NSAIDs carry FDA black box warnings regarding cardiovascular risk 1, though the risk is lower than with oral formulations.