What are the contraindications for Voltaren (diclofenac) gel?

Contraindications for Voltaren Gel (Diclofenac Sodium Topical Solution)

Voltaren gel is contraindicated in patients with known hypersensitivity to diclofenac, history of asthma or allergic reactions after taking aspirin or other NSAIDs, and in the setting of coronary artery bypass graft (CABG) surgery. 1

Absolute Contraindications

• Known hypersensitivity to diclofenac or any components of the product (including anaphylactic reactions and serious skin reactions) 1
• History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs (severe, sometimes fatal anaphylactic reactions have been reported in such patients) 1
• In the setting of coronary artery bypass graft (CABG) surgery 1

Relative Contraindications/Use with Caution

Cardiovascular Risks

• Patients with established cardiovascular disease or risk factors 1
• History of myocardial infarction or stroke 1
• Heart failure (avoid in severe heart failure) 1
• Hypertension (may worsen blood pressure control) 1, 2

Gastrointestinal Risks

• History of peptic ulcer disease 3
• History of gastrointestinal bleeding 1
• Concomitant use with aspirin (increases risk of serious GI events) 1
• Elderly patients (higher risk of GI adverse events) 1

Renal Considerations

• Advanced renal disease 1
• Renal impairment 1
• Dehydration or hypovolemia 1

Pregnancy-Related

• Pregnancy, especially between 20-30 weeks (risk of oligohydramnios/fetal renal dysfunction) 1
• Pregnancy after 30 weeks gestation (risk of premature closure of the fetal ductus arteriosus) 1

Other Important Considerations

• Concomitant use with oral NSAIDs (avoid) 1
• Liver disease or elevated liver enzymes 1
• Bleeding disorders or concurrent anticoagulant therapy 2
• Exposure of treated area to natural or artificial sunlight (should be avoided) 1

Special Populations Requiring Caution

Despite topical diclofenac having fewer systemic effects than oral formulations, caution should still be exercised in:

• Elderly patients (>60 years) 2
• Patients on concurrent corticosteroid therapy 2
• Patients with untreated H. pylori infection 2
• Patients on anticoagulants (warfarin, heparin, DOACs) 2

Clinical Pearls and Precautions

1. Systemic absorption risk: Even with topical application, some systemic absorption occurs that can lead to adverse effects, including upper GI hemorrhage in susceptible individuals 3

2. Cardiovascular monitoring: Patients with cardiovascular risk factors should be monitored, as even topical NSAIDs may contribute to cardiovascular risk 1

3. Concomitant medications: Be cautious when prescribing to patients on:

   • Low-dose aspirin (may reduce cardioprotective effects) 2
   • Anticoagulants (increased bleeding risk) 2
   • Antihypertensives (may reduce effectiveness) 1

4. Eye contact: Avoid contact with eyes and mucosa 1

5. Duration of use: Use the lowest effective dose for the shortest duration possible to minimize potential risks 1

While long-term studies have suggested that topical diclofenac may be safer than oral NSAIDs in elderly patients and those with comorbidities like hypertension, type 2 diabetes, and cardiovascular disease 4, the same contraindications should be considered due to potential systemic absorption.

When prescribing Voltaren gel, always assess the patient's complete medical history, focusing particularly on cardiovascular status, renal function, history of GI bleeding, and hypersensitivity reactions to ensure safe use of this medication.