What are the alternatives to Diclofenac (Voltaren) gel?

Alternatives to Diclofenac Gel

The best alternatives to diclofenac gel are other topical NSAIDs (ketoprofen gel or ibuprofen gel) for localized musculoskeletal pain, or lidocaine 5% patch for neuropathic pain, depending on the underlying pain mechanism.

Topical NSAID Alternatives

Ketoprofen Gel

• Ketoprofen gel is highly effective with an NNT of 2.5 (2.0 to 3.4) for acute musculoskeletal pain, making it comparable to or better than diclofenac gel 1
• For chronic conditions like knee osteoarthritis, ketoprofen gel over 6-12 weeks shows 63% response versus 48% placebo (NNT 6.9), with moderate-quality evidence 2
• Ketoprofen gel demonstrated efficacy similar to oral celecoxib in reducing knee OA pain 3

Ibuprofen Gel

• Ibuprofen gel has an NNT of 3.9 (2.7 to 6.7) for acute pain with marked improvement or complete remission 1
• Provides pain relief comparable to oral ibuprofen for localized musculoskeletal conditions 4
• High-quality evidence shows local and systemic adverse events (4.3%) are no greater than placebo (4.6%) 2

Piroxicam Gel

• Piroxicam gel shows efficacy with 70% response versus 47% placebo (NNT 4.4) in acute musculoskeletal pain 2
• Demonstrated equal efficacy to ketoprofen gel in comparative trials 4

Topical Anesthetic Alternative

Lidocaine 5% Patch

• Apply daily to the painful site with minimal systemic absorption 4
• Particularly effective for neuropathic pain conditions including postherpetic neuralgia and diabetic peripheral neuropathic pain 3
• May be useful for complex regional pain syndrome 3
• Especially valuable when anticoagulation is present, as oral NSAIDs should be avoided but topical agents like lidocaine patch remain safe 4

Capsaicin Formulations

High-Concentration Capsaicin

• For chronic neuropathic pain (particularly postherpetic neuralgia), high-concentration capsaicin shows moderate efficacy with 33% response versus 24% placebo (NNT 11) 2
• Local adverse events are common (63% versus placebo), with NNH of 2.6 for local reactions 2

Low-Concentration Capsaicin

• Available for chronic soft-tissue pain 3
• Higher withdrawal rates due to adverse events (15% versus 3% placebo, NNH 8) 2

Clinical Decision Algorithm

For acute musculoskeletal pain (sprains, strains):

• First choice: Ketoprofen gel (NNT 2.5) or ibuprofen gel (NNT 3.9) 1
• Apply 3 times daily to affected area 4

For chronic musculoskeletal pain (osteoarthritis):

• Ketoprofen gel over 6-12 weeks for hand/knee OA 2
• Consider topical formulation based on patient preference (gel versus patch) 5

For neuropathic pain:

• Lidocaine 5% patch as first-line topical agent 4
• High-concentration capsaicin for postherpetic neuralgia if lidocaine insufficient 2

For patients on anticoagulation:

• Topical NSAIDs (any formulation) or lidocaine patch are safe alternatives, as oral NSAIDs must be avoided 4

Important Caveats

Formulation matters critically - the exact gel, cream, or patch formulation significantly impacts efficacy, particularly in acute conditions 2, 1

Combination therapy - topical agents can be used as co-analgesics with opioids, antidepressants, or anticonvulsants for multimodal pain management 4

Older adults - topical NSAIDs are particularly beneficial due to reduced systemic adverse effects compared to oral NSAIDs 5

Application frequency - most topical NSAIDs require 3-times-daily application for optimal efficacy 4