Can you take systemic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) with Voltaren (diclofenac) gel?

Concurrent Use of Systemic NSAIDs with Topical Diclofenac (Voltaren) Gel

Combining systemic NSAIDs with topical diclofenac gel is not recommended due to increased risk of adverse effects without additional therapeutic benefit.

Understanding the Risks

Concurrent use of multiple NSAIDs (including combinations of oral and topical forms) presents several significant risks:

Increased Adverse Effects

• Gastrointestinal complications: The combination of oral NSAIDs with topical diclofenac has been shown to increase the risk of rectal hemorrhage (3% vs. less than 1%) compared to oral NSAIDs alone 1
• Renal complications: Combination therapy results in more frequent abnormal creatinine (12% vs. 7%) and urea (20% vs. 12%) levels 1
• Hematological effects: Higher rates of abnormal hemoglobin (13% vs. 9%) have been observed with combination therapy 1

Lack of Additional Benefit

• Concomitant use of diclofenac with other NSAIDs or salicylates increases the risk of GI toxicity with little or no increase in efficacy 1
• The American Heart Association warns that combination NSAID therapy has "no pharmacological justification" 2

Evidence-Based Recommendations

FDA Drug Label Guidance

The FDA drug label for topical diclofenac explicitly states:

• "The concomitant use of diclofenac with other NSAIDs or salicylates is not recommended" 1
• "Do not use combination therapy with diclofenac sodium topical solution and an oral NSAID unless the benefit outweighs the risk" 1

Clinical Guidelines Support

Multiple clinical guidelines reinforce this recommendation:

• The American Heart Association cautions against concurrent use of multiple NSAIDs 2
• The American College of Rheumatology recommends avoiding NSAID combinations 2
• A case/non-case study from the French Pharmacovigilance system found that the risk of severe adverse drug reactions was six- to sevenfold higher with concomitant use of two or more NSAIDs 3

Alternative Approaches

If you need pain relief beyond what topical diclofenac provides, consider these safer alternatives:

For Localized Pain

• Topical diclofenac alone: Topical NSAIDs have favorable safety profiles compared to oral analgesics with beneficial effects on pain and function 2
• Other topical agents: Consider topical lidocaine or capsaicin as alternatives 4

For Systemic Pain Relief

• Acetaminophen: First-line pharmacological treatment with better safety profile 4
• Low-dose opioids: For short-term use when other options fail 4

Special Considerations

Elderly Patients

• Older adults are at higher risk for NSAID-related adverse effects 2
• Topical diclofenac alone has been shown to be safe in elderly patients 5

Patients with Comorbidities

• Patients with hypertension, cardiovascular disease, or renal impairment are at particularly high risk for adverse effects from NSAID combinations 4
• Long-term topical diclofenac alone appears safe even in patients with comorbidities such as hypertension, diabetes, and cardiovascular disease 5

Monitoring if Combination Use is Unavoidable

If, despite these warnings, combination therapy is deemed necessary:

• Conduct periodic laboratory evaluations 1
• Monitor for signs of:
  • Gastrointestinal bleeding
  • Worsening renal function
  • Cardiovascular events
  • Use the lowest effective doses for the shortest duration possible

Remember that topical diclofenac provides effective localized pain relief with minimal systemic absorption 6, 7, making it a safer option than adding a second systemic NSAID.