Can you take ibuprofen (Nonsteroidal Anti-Inflammatory Drug (NSAID)) and use diclofenac (NSAID) topical at the same time?

Concurrent Use of Oral Ibuprofen and Topical Diclofenac

Concurrent use of oral ibuprofen and topical diclofenac is not recommended due to increased risk of adverse effects without substantial additional therapeutic benefit. 1

Risks of Combining NSAIDs

• The FDA explicitly warns against combining topical diclofenac with oral NSAIDs, stating: "do not use combination therapy with diclofenac sodium topical solution and an oral NSAID unless the benefit outweighs the risk" 2
• Concurrent use of multiple NSAIDs increases the risk of gastrointestinal toxicity with little or no increase in efficacy 2
• When oral NSAIDs were combined with topical diclofenac in clinical trials, there was a higher rate of rectal hemorrhage (3% vs. less than 1%) and more frequent abnormal laboratory values for creatinine, urea, and hemoglobin compared to oral NSAIDs alone 2

Specific Risks to Consider

Gastrointestinal Risks

• Both oral and topical NSAIDs are associated with increased risk of gastrointestinal bleeding, ulceration, and perforation 3
• The risk of GI complications is dose-dependent, with higher doses and combination therapy increasing the risk 3

Cardiovascular Risks

• NSAIDs increase the risk of cardiovascular events, including myocardial infarction and stroke 3
• Diclofenac specifically has been identified as possessing potentially higher risk for adverse cardiovascular events compared to other NSAIDs 3, 4
• The cardiovascular risks of NSAIDs are dose- and duration-dependent 5

Alternative Approaches

Use Topical NSAID Alone

• Topical NSAIDs such as diclofenac have been developed to avert systemic NSAID-related adverse effects 3
• Topical diclofenac alone is effective for localized pain and has fewer systemic side effects due to lower systemic absorption 1, 6
• For persons age ≥75 years, topical NSAIDs are strongly recommended over oral NSAIDs 3

Use Oral NSAID Alone

• If systemic anti-inflammatory effects are needed, using a single NSAID at the lowest effective dose for the shortest duration is recommended 1
• Recent research shows that oral ibuprofen alone may be more effective than topical diclofenac alone for certain conditions like acute low back pain 7

Consider Non-NSAID Alternatives

• Acetaminophen can be considered as a first-line alternative, particularly in patients at high risk for NSAID-related adverse events 3, 1
• If pain relief is inadequate with acetaminophen, consider other analgesics rather than combining multiple NSAIDs 3

Special Considerations

High-Risk Populations

• Older adults are at particularly high risk for NSAID-related adverse effects 3, 1
• Patients with a history of gastrointestinal bleeding, cardiovascular disease, or renal impairment should be especially cautious with any NSAID use 3, 1
• NSAIDs may adversely affect blood pressure control, renal function, and heart failure management 3

If NSAID Use Is Necessary

• If NSAID therapy is unavoidable, consider adding a proton pump inhibitor for gastroprotection, especially in high-risk patients 3
• Monitor renal function, blood pressure, and watch for signs of gastrointestinal bleeding in patients taking any NSAID 3
• For short-term use (less than 4 weeks) and at lower doses, the risks of adverse effects are lower 3, 5

Bottom Line

• Choose either oral ibuprofen OR topical diclofenac, but not both together 2
• For localized pain in older adults or those with high cardiovascular/gastrointestinal risk, prefer topical diclofenac 3, 1
• For more widespread pain requiring systemic effects, use oral ibuprofen alone at the lowest effective dose for the shortest duration 1, 7