What is the preferred choice between diclofenac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) and ibuprofen (NSAID) for patients requiring NSAID therapy?

Diclofenac vs Ibuprofen: Choosing the Optimal NSAID

For patients requiring NSAID therapy, ibuprofen is generally preferred over diclofenac due to its better cardiovascular safety profile and lower risk of adverse events, particularly at lower doses. 1

Comparative Safety Profiles

Cardiovascular Risk

• Ibuprofen has a lower cardiovascular risk profile compared to diclofenac, which is particularly important for patients with or at risk for cardiovascular disease 1
• Diclofenac has been associated with higher cardiovascular risk similar to some COX-2 inhibitors 1
• In patients with prior myocardial infarction, mortality risk was higher with diclofenac (HR 2.40) compared to ibuprofen (HR 1.50) 1

Gastrointestinal Safety

• Both NSAIDs carry GI risks, but ibuprofen at lower doses (≤1200 mg/day) has a safety profile comparable to paracetamol 2
• For patients at higher risk of GI complications, ibuprofen is considered among the NSAIDs with lower GI risk 1

Drug Interactions

• Important consideration: Ibuprofen interferes with aspirin's cardioprotective effects, while diclofenac does not 1
• If a patient is on low-dose aspirin, diclofenac may be preferred, or ibuprofen should be taken at least 30 minutes after aspirin or 8 hours before 1

Efficacy Comparison

• Both drugs demonstrate similar efficacy for pain relief in most conditions 3, 4, 5, 6
• For postoperative pain, diclofenac 50mg (NNT 2.3) and ibuprofen 400mg (NNT 2.7) showed comparable efficacy 5, 6
• In osteoarthritis, some studies suggest sustained-release ibuprofen may have advantages over diclofenac in terms of efficacy and tolerability 4

Dosing Considerations

• Ibuprofen: Start with lower doses (1200 mg/day) and increase if needed 1
• Diclofenac: Typically prescribed at 50-100 mg/day
• Lower doses of either drug are preferred to minimize adverse effects 1

Algorithm for NSAID Selection

1. Assess patient risk factors:

   • Cardiovascular risk: If present → prefer ibuprofen at lowest effective dose
   • GI risk: If present → consider adding PPI regardless of NSAID choice
   • On aspirin therapy: If yes → prefer diclofenac or ensure proper timing with ibuprofen

2. Based on specific condition:

   • Acute pain/fever: Either drug effective; ibuprofen preferred for safety
   • Osteoarthritis: Start with ibuprofen; consider diclofenac for inadequate response
   • Postoperative pain: Either drug effective at appropriate doses

3. Dosing approach:

   • Start with lowest effective dose
   • For ibuprofen: Begin with 1200 mg/day
   • For diclofenac: Begin with 50 mg/day
   • Limit duration of treatment to shortest period necessary

Important Caveats

• All NSAIDs should be used at the lowest effective dose for the shortest duration possible 1
• Neither drug should be used in patients with advanced kidney disease (eGFR <30 ml/min) 1
• For patients aged ≥75 years, topical NSAIDs are preferred over oral formulations 1
• In patients with high cardiovascular risk, consider alternative analgesics before NSAIDs (acetaminophen, tramadol) 1
• Monitor renal function and blood pressure in all patients on NSAID therapy 1

In summary, while both drugs are effective for pain management, ibuprofen generally offers a more favorable safety profile, particularly regarding cardiovascular risk, making it the preferred first-line NSAID for most patients requiring this class of medication.