What specific topical nonsteroidal anti-inflammatory drug (NSAID) can be offered to a patient on apixaban (eliquis) with muscular back pain?

Topical Diclofenac is the Optimal Topical NSAID for a Patient on Apixaban with Muscular Back Pain

For patients on apixaban with muscular back pain, topical diclofenac is the recommended first-line topical NSAID due to its proven efficacy and favorable safety profile compared to oral NSAIDs. 1

Rationale for Topical NSAIDs in Anticoagulated Patients

Patients on apixaban (Eliquis) have an increased bleeding risk, making topical NSAIDs particularly advantageous:

• Topical NSAIDs are strongly recommended as first-line therapy for musculoskeletal pain by the American College of Physicians and American Academy of Family Physicians 1
• Topical NSAIDs provide effective pain relief with minimal systemic absorption, reducing the risk of drug interactions with apixaban
• Topical administration avoids the gastrointestinal and cardiovascular risks associated with oral NSAIDs 1

Specific Topical NSAID Recommendations

First Choice: Topical Diclofenac

• Diclofenac gel/solution (1-1.3%) has the strongest evidence for efficacy in musculoskeletal pain 2
• Available formulations include:
  • Diclofenac gel (Voltaren, now OTC)
  • Diclofenac solution with DMSO (Pennsaid)
  • Diclofenac epolamine patch (Flector)

Application Instructions

• Apply to affected area 3-4 times daily (gel/solution) or every 12 hours (patch)
• Use the smallest effective amount
• Avoid application to broken or irritated skin
• Wash hands thoroughly after application unless treating hands

Evidence Supporting Topical Diclofenac

Topical diclofenac has demonstrated effectiveness in multiple high-quality studies:

• Systematic review of 11,000+ participants showed topical diclofenac is effective for both acute and chronic musculoskeletal pain 2
• For acute pain, diclofenac gel showed an NNT of 1.8 (95% CI 1.5-2.1), indicating excellent efficacy 2
• Diclofenac epolamine patch 1.3% significantly reduced pain in patients with acute back strain, with mean pain scores decreasing from 6.5 to 2.5 (p<0.0001) 3
• Local adverse events are minimal (4.1% in acute pain studies) 2

Alternative Topical Options

If diclofenac is unavailable or not tolerated:

• Topical NSAIDs with menthol gel are also recommended as first-line therapy 1
• Other topical NSAIDs (ketoprofen, ibuprofen) may be considered but have less robust evidence

Important Considerations for Patients on Apixaban

1. Safety Profile: Topical NSAIDs have significantly lower systemic absorption compared to oral NSAIDs, making them safer for patients on anticoagulants 1

2. Monitoring: Despite minimal systemic absorption, monitor for:

   • Skin reactions at application site
   • Any unusual bleeding or bruising
   • Signs of rare systemic effects

3. Duration of Use: Use for the shortest period necessary to control symptoms

When to Consider Other Approaches

If topical NSAIDs provide insufficient relief:

1. First step: Add acetaminophen (up to 3g daily) as it has minimal interaction with apixaban 1

2. Second step: Consider non-pharmacological approaches:

   • Heat application
   • Physical therapy
   • Gentle exercise as tolerated

3. Third step: If pain remains severe, consider consultation with pain specialist for additional options

Caution

• Avoid oral NSAIDs in patients on apixaban due to increased bleeding risk 1
• Even with topical NSAIDs, use the lowest effective dose for the shortest duration
• Advise patients to report any unusual bleeding or bruising

Topical diclofenac provides an effective and safer alternative to oral NSAIDs for patients on apixaban, offering localized pain relief while minimizing systemic effects and potential drug interactions.