What are the risks of using Voltaren (Diclofenac) gel and Ibuprofen (Non-Steroidal Anti-Inflammatory Drug (NSAID)) concurrently?

Risks of Using Voltaren Gel and Ibuprofen Concurrently

Using Voltaren (diclofenac) gel and oral ibuprofen together significantly increases the risk of gastrointestinal bleeding, cardiovascular events, and renal toxicity, and this combination should be avoided whenever possible. 1, 2

Increased Risk of Adverse Events

Gastrointestinal Risks

• Concomitant use of multiple NSAIDs (including topical diclofenac with oral ibuprofen) increases the risk of gastrointestinal toxicity with little or no increase in efficacy 1
• Clinical trials have shown that combination therapy with topical diclofenac and oral NSAIDs resulted in:
  • Higher rates of rectal hemorrhage (3% vs. less than 1%)
  • More frequent abnormal laboratory values including creatinine (12% vs. 7%), urea (20% vs. 12%), and hemoglobin (13% vs. 9%) 1

Cardiovascular Risks

• Both diclofenac and ibuprofen carry FDA black box warnings for increased risk of cardiovascular thrombotic events 3
• The risk increases with duration of use and is higher in patients with existing cardiovascular disease or risk factors 3
• While low-dose, short-term use of either agent alone may have minimal cardiovascular risk, combining them may amplify this risk 4

Renal Risks

• NSAIDs inhibit renal prostaglandin synthesis, which can lead to:
  • Reduced renal blood flow
  • Sodium and water retention
  • Worsening hypertension
  • Potential acute kidney injury 1
• These risks are heightened when multiple NSAIDs are used concurrently 3

Special Populations at Higher Risk

The risks of concurrent NSAID use are particularly elevated in:

1. Elderly patients (≥60 years) 3, 2
2. Patients with existing gastrointestinal conditions (history of ulcers, bleeding) 2
3. Patients with cardiovascular disease or risk factors 3
4. Patients with compromised renal function 3, 1
5. Patients taking other medications that increase bleeding risk (anticoagulants, corticosteroids, aspirin) 2

Drug Interaction Considerations

• If aspirin is also being taken for cardioprotection, there's a specific timing issue: ibuprofen can interfere with aspirin's cardioprotective effects if not properly timed 3
• Guidelines recommend taking ibuprofen at least 30 minutes after immediate-release aspirin or at least 8 hours before aspirin to avoid diminishing aspirin's protective effects 3

Recommendations

1. Avoid concurrent use of topical diclofenac and oral ibuprofen whenever possible 1

2. If pain management requires more than one agent:

   • Consider acetaminophen instead of a second NSAID 3
   • Use the lowest effective dose for the shortest duration possible 2
   • Consider non-pharmacological pain management approaches

3. If combination therapy is absolutely necessary:

   • Conduct regular laboratory monitoring (renal function, complete blood count) 1
   • Monitor for signs of GI bleeding (dark stools, abdominal pain)
   • Watch for signs of cardiovascular issues (chest pain, shortness of breath)
   • Consider gastroprotection with proton pump inhibitors 2

Alternative Approaches

• For musculoskeletal pain, recent evidence suggests that topical diclofenac alone may be sufficient for many patients, with fewer systemic side effects than oral NSAIDs 5
• For more severe pain, using either topical diclofenac OR oral ibuprofen (not both) with acetaminophen may provide better safety profile 3
• For acute low back pain specifically, research suggests oral ibuprofen may be more effective than topical diclofenac, making it the preferred single agent in this scenario 6

The FDA explicitly warns against the concomitant use of diclofenac with other NSAIDs or salicylates due to increased risk of gastrointestinal toxicity with little or no increase in efficacy 1.