Is it okay to use Voltaren (diclofenac) gel and ibuprofen three times a day (tid) concurrently?

Concurrent Use of Voltaren Gel and Oral Ibuprofen

Using Voltaren (diclofenac) gel with oral ibuprofen three times daily is not recommended due to increased risk of gastrointestinal, cardiovascular, and renal adverse effects without additional analgesic benefit.

Rationale for Recommendation

Pharmacological Considerations

• Both diclofenac (Voltaren gel) and ibuprofen are NSAIDs that work through similar mechanisms - inhibiting cyclooxygenase (COX) enzymes 1
• Topical diclofenac is absorbed systemically, though at lower concentrations than oral formulations
• Using two NSAIDs concurrently provides minimal additional pain relief but significantly increases risk of adverse effects 1, 2

Evidence on Combined NSAID Use

• The American Heart Association specifically warns against concomitant use of multiple NSAIDs, stating: "The concomitant use of diclofenac with other NSAIDs or salicylates is not recommended" 2
• Clinical trials show that combining topical diclofenac with oral NSAIDs results in higher rates of adverse events, including:
  • Higher rates of rectal hemorrhage (3% vs. <1%)
  • More frequent abnormal creatinine (12% vs. 7%)
  • Elevated urea (20% vs. 12%)
  • Abnormal hemoglobin (13% vs. 9%) 2
• A recent randomized study found that combining topical diclofenac with oral ibuprofen provided no additional benefit over either agent alone for acute low back pain 3

Risks of Concurrent Use

Cardiovascular Risks

• Both diclofenac and ibuprofen increase risk of cardiovascular events 1
• Diclofenac is associated with a 63% increased risk of vascular events (RR 1.63,95% CI 1.12-2.37) 1
• Ibuprofen shows a 51% increased risk (RR 1.51,95% CI 0.96-2.37) 1
• Combined use may potentially compound these risks

Gastrointestinal Risks

• NSAIDs cause increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation 1
• Patients at higher risk include those:
  • Over age 60
  • With history of peptic ulcer disease
  • With significant alcohol use
  • With major organ dysfunction 1

Renal Risks

• NSAIDs can cause acute kidney injury, especially in:
  • Patients over 60 years
  • Those with compromised fluid status
  • Those with pre-existing renal disease
  • Patients taking other nephrotoxic medications 1

Alternative Approaches

If Pain Management is Needed

1. Use a single NSAID only:

   • Either topical diclofenac OR oral ibuprofen, not both 2
   • Topical diclofenac may have fewer systemic side effects than oral NSAIDs 3

2. Consider non-NSAID alternatives:

   • Acetaminophen (paracetamol) is a safer option without antiplatelet effects 4
   • For more severe pain, consider consultation with a healthcare provider about appropriate non-NSAID options

If Using a Single NSAID

• Monitor for signs of GI toxicity: abdominal pain, black stools, vomiting blood
• Monitor for signs of renal toxicity: decreased urine output, fluid retention
• Monitor for cardiovascular symptoms: chest pain, shortness of breath, edema
• Consider baseline and periodic monitoring of blood pressure, renal function, and liver function tests with prolonged use 1

Special Considerations

• If you are taking low-dose aspirin for cardiovascular protection, be aware that ibuprofen can interfere with aspirin's cardioprotective effects 5
• Diclofenac does not interfere with aspirin's antiplatelet effects and may be preferable if an NSAID is needed while on aspirin therapy 5
• Elderly patients, those with cardiovascular disease, renal impairment, or history of GI bleeding are at particularly high risk for NSAID-related adverse events 1

Remember that all NSAIDs carry risks, and using the lowest effective dose for the shortest duration is always the safest approach when these medications are needed.