Diclofenac Use in Patients with Hypertension
Diclofenac should be used with caution in hypertensive patients as it can lead to new onset hypertension or worsen pre-existing hypertension, potentially contributing to increased cardiovascular events. 1
Cardiovascular Risks of Diclofenac
- Diclofenac has a higher cardiovascular risk profile compared to other NSAIDs, with meta-analyses showing a 63% increased risk of vascular events compared to placebo (RR 1.63,95% CI 1.12-2.37) 2
- Diclofenac has been associated with a 54% increased risk of recurrent myocardial infarction (RR 1.54,95% CI 1.23-1.93) and a 240% increased risk of mortality (RR 2.40,95% CI 2.09-2.80) 2
- NSAIDs, including diclofenac, can blunt the cardiovascular effects of several antihypertensive agents, including diuretics, ACE inhibitors, and angiotensin receptor blockers 1
Recommendations for Diclofenac Use in Hypertensive Patients
General Precautions
- Monitor blood pressure during the initiation of diclofenac treatment and throughout the course of therapy 1
- Use the lowest effective dose for the shortest duration possible to minimize cardiovascular risk 2, 1
- Avoid diclofenac in patients with treatment-resistant hypertension or high cardiovascular risk 3
Specific Patient Populations
- For patients with hypertension and requiring pain management:
- Consider acetaminophen as first-line therapy when appropriate, as it has a better cardiovascular safety profile 2
- If NSAID therapy is necessary, naproxen may be preferred over diclofenac due to its more favorable cardiovascular risk profile 2, 3
- For patients at high cardiovascular risk requiring an NSAID, naproxen or celecoxib are preferred over diclofenac 3
Monitoring Recommendations
- Measure blood pressure before starting diclofenac treatment 3
- Monitor blood pressure within 1-2 weeks of initiating diclofenac therapy 1
- Monitor renal function in patients with hypertension taking diclofenac, especially those on antihypertensive medications 1
Interactions with Antihypertensive Medications
- Patients taking ACE inhibitors, thiazide diuretics, or loop diuretics may have impaired response to these therapies when taking diclofenac or other NSAIDs 1
- For patients with pre-existing hypertension receiving renin-angiotensin system blockers, consider empirical addition or increase in the dose of an antihypertensive agent of a different class when initiating diclofenac 3
- Some studies suggest that the combination of lisinopril and hydrochlorothiazide may maintain blood pressure control even with concomitant diclofenac use 4, but this finding should be interpreted with caution given the stronger evidence of NSAID interference with antihypertensive medications
Special Considerations
- Misoprostol co-administration may attenuate diclofenac-induced blood pressure elevation and renal vasoconstriction in salt-sensitive hypertensive patients 5
- In patients with heart failure, avoid diclofenac unless benefits are expected to outweigh the risk of worsening heart failure 1
- For patients requiring both antiplatelet therapy and pain management, be aware that ibuprofen may interfere with aspirin's cardioprotective effects, while diclofenac does not appear to have this interaction 2
Common Pitfalls to Avoid
- Failing to monitor blood pressure after initiating diclofenac therapy 1
- Using diclofenac in patients with severe heart failure or advanced renal disease 1
- Not considering alternative pain management strategies in high-risk hypertensive patients 2
- Overlooking the potential for diclofenac to counteract the effects of antihypertensive medications 2
By carefully considering these recommendations and monitoring patients appropriately, the risks associated with diclofenac use in hypertensive patients can be minimized while still providing effective pain management.