Is topical Voltaren (diclofenac) safe for a patient with a history of myocardial infarction (heart attack)?

Safety of Topical Voltaren (Diclofenac) in Patients with History of Heart Attack

Topical diclofenac (Voltaren) is generally safe for patients with a history of myocardial infarction, as the systemic absorption is minimal compared to oral NSAIDs, but caution is still warranted in high-risk cardiac patients.

Risk Assessment of Topical Diclofenac

Cardiovascular Safety Profile

• The FDA drug label for topical diclofenac indicates that while NSAIDs can increase the risk of serious cardiovascular thrombotic events, including myocardial infarction, this risk is primarily associated with oral formulations and higher systemic exposure 1
• Topical diclofenac provides significantly lower systemic exposure compared to oral NSAIDs, which reduces cardiovascular risk
• Research shows that topical diclofenac has favorable safety profiles even in elderly patients, with primarily local adverse effects rather than systemic ones 2

Key Considerations for Post-MI Patients

• The FDA label specifically mentions that "patients with known CV disease or risk factors had a higher absolute incidence of excess serious CV thrombotic events" 1
• For post-MI patients, the label states: "Avoid the use of diclofenac sodium topical solution in patients with a recent MI unless the benefits are expected to outweigh the risk of recurrent CV thrombotic events" 1
• The risk appears to be dose-dependent and duration-dependent, with higher risks associated with higher systemic exposure 1

Clinical Decision-Making Algorithm

1. Assess time since MI:

   • If MI occurred within past 12 months: Use extra caution
   • If MI occurred >12 months ago: Lower risk but still consider cardiac status

2. Evaluate current cardiac status:

   • Stable with well-controlled risk factors: Lower risk
   • Unstable or poorly controlled risk factors: Higher risk

3. Consider alternative treatments:

   • Acetaminophen as first-line therapy 3
   • Non-pharmacological approaches (physical therapy, heat/cold therapy)

4. If topical diclofenac is selected:

   • Use lowest effective dose
   • Apply to smallest affected area
   • Use for shortest duration necessary
   • Monitor for any cardiovascular symptoms

Practical Recommendations

• Application technique: Apply thinly over affected area only, avoid excessive amounts
• Frequency: Follow package instructions (typically 2-4 times daily)
• Duration: Use for shortest period necessary to control symptoms
• Monitoring: Be alert for signs of cardiovascular events (chest pain, shortness of breath)
• Avoid combination: Do not use topical diclofenac concurrently with oral NSAIDs 1

Important Precautions

• Avoid use if patient has had CABG surgery 1
• Use caution in patients with heart failure 1
• Patients should be informed about potential cardiovascular risks and warning signs
• Consider periodic cardiac monitoring in high-risk patients using topical diclofenac long-term

Evidence-Based Perspective

The evidence regarding topical diclofenac specifically in post-MI patients is limited. However, studies show that the systemic absorption of topical diclofenac is approximately 6-10% of oral formulations, significantly reducing cardiovascular risk 2. While oral diclofenac has been associated with increased risk of myocardial infarction 4, 5, topical formulations have not demonstrated the same level of risk due to minimal systemic absorption.

In summary, while caution is warranted, topical diclofenac can be considered for patients with a history of myocardial infarction when benefits outweigh risks, particularly when used at the lowest effective dose for the shortest duration necessary.