Concurrent Use of Ibuprofen and Diclofenac
No, ibuprofen and diclofenac should not be used together—combining two NSAIDs increases the risk of serious adverse effects without providing additional therapeutic benefit. 1, 2
Why Combining NSAIDs Is Contraindicated
The concurrent use of multiple NSAIDs multiplies toxicity risks across all organ systems without enhancing analgesic efficacy. 1, 2 This practice specifically increases:
- Gastrointestinal bleeding risk by 3-6 times compared to single NSAID use, with both drugs independently causing gastric mucosal injury through COX-1 inhibition 1
- Cardiovascular complications including myocardial infarction, stroke, and worsening heart failure, as each NSAID carries independent thrombotic risk 1
- Renal impairment through additive effects on renal perfusion and sodium retention 1
- Hepatotoxicity, particularly with diclofenac which already carries large increases in hepatic harms 1, 3
The Critical Distinction Between These Two NSAIDs
If choosing between these medications (not combining them), understand their different risk profiles:
Diclofenac carries significantly higher cardiovascular risk with a relative risk of 1.63 (95% CI 1.12-2.37) for major coronary events compared to placebo, while ibuprofen shows no clearly increased cardiovascular risk at doses ≤1200 mg daily 4, 5. Diclofenac's COX-2 selectivity places it closer to the withdrawn rofecoxib on the thrombotic risk spectrum 1, 4.
For patients with cardiovascular disease or risk factors, ibuprofen is strongly preferred over diclofenac due to this more favorable cardiovascular safety profile 1, 4.
What To Do Instead
Select a single NSAID based on the patient's specific risk profile:
- For patients with cardiovascular risk factors: Choose ibuprofen ≤1200 mg daily, which shows no clear cardiovascular risk at this dose 1, 4, 5
- For patients with gastrointestinal risk factors: Add proton pump inhibitor co-therapy regardless of which NSAID is selected, as both carry moderate-to-large GI bleeding risk 1, 4
- For patients requiring aspirin for cardioprotection: If using ibuprofen, dose it at least 30 minutes after immediate-release aspirin or at least 8 hours before aspirin to avoid interference with aspirin's antiplatelet effect 1
Efficacy Comparison When Choosing Between Them
Diclofenac 50-100 mg demonstrates superior analgesic efficacy compared to ibuprofen 400-1200 mg with NNTs of 2.3 and 1.8 respectively versus ibuprofen's NNTs of 2.7-3.3 6. However, this modest efficacy advantage does not justify its use in patients with cardiovascular risk factors given the significantly elevated thrombotic risk 4.
Common Pitfalls to Avoid
- Never assume that combining NSAIDs at lower doses is safer than using one at full dose—the adverse effects are additive while efficacy is not 1, 2
- Do not switch between NSAIDs without a washout period—overlapping use creates the same risks as intentional combination 1
- Avoid prescribing either NSAID for longer than necessary—cardiovascular and GI risks are highest in the first 6 months but increase with duration 1, 4
- Monitor blood pressure, renal function, and consider fecal occult blood testing when any NSAID is prescribed, particularly in elderly patients or those with comorbidities 1