What are the contraindications for Voltaren (diclofenac)?

Contraindications of Voltaren (Diclofenac)

Diclofenac is absolutely contraindicated in patients with known hypersensitivity to the drug, history of asthma or allergic reactions to aspirin or other NSAIDs, and in the setting of coronary artery bypass graft (CABG) surgery. 1

Absolute Contraindications

Hypersensitivity Reactions

• Known hypersensitivity to diclofenac or any drug components, including anaphylactic reactions and serious skin reactions 1
• History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs, as severe and sometimes fatal anaphylactic reactions have been reported in such patients 1

Perioperative Setting

• In the setting of coronary artery bypass graft (CABG) surgery, due to increased risk of cardiovascular thrombotic events 1

Strong Relative Contraindications (Avoid Unless Benefits Clearly Outweigh Risks)

Cardiovascular Disease

• Patients with established ischemic heart disease or prior myocardial infarction should avoid diclofenac due to a 2.4-fold increased mortality risk (RR 2.40,95% CI 2.09-2.80) and 1.54-fold increased risk of recurrent MI 2
• Patients with cardiac pain or unstable angina, as diclofenac carries risks comparable to withdrawn drugs like rofecoxib 2
• The European Society of Cardiology notes that diclofenac should be avoided as first-line analgesia in patients with ischemic heart disease or stroke 3

Heart Failure

• Severe heart failure is a strong relative contraindication; avoid use unless benefits are expected to outweigh the risk of worsening heart failure 1
• If used in severe heart failure, monitor patients closely for signs of worsening 1

Renal Impairment

• Advanced renal disease or chronic kidney disease stage IV-V (eGFR <30 mL/min) should avoid diclofenac unless benefits clearly outweigh risks of worsening renal function 2, 1
• Chronic kidney disease stage III (eGFR 30-59 mL/min) requires careful risk-benefit assessment before use 2

Gastrointestinal Risk Factors

• History of peptic ulcer disease or gastrointestinal bleeding within the past year represents a strong relative contraindication 2
• Elderly patients ≥75 years should preferentially use topical rather than oral NSAIDs due to increased GI bleeding risk 2

Pregnancy

• At approximately 30 weeks gestation and later, avoid diclofenac due to risk of premature closure of fetal ductus arteriosus 1
• At approximately 20 weeks gestation and later, use may cause fetal renal dysfunction leading to oligohydramnios and neonatal renal impairment 1

High-Risk Situations Requiring Extreme Caution

Anticoagulation Therapy

• Patients on anticoagulants face a 3-6 fold increased bleeding risk and require extreme caution or avoidance 2
• If diclofenac must be used, maximize non-NSAID analgesics, add proton pump inhibitor therapy, and monitor closely for bleeding 2

Multiple Risk Factors

• Patients taking ACE inhibitors, ARBs, or diuretics are at increased risk of renal decompensation 1
• Dehydrated or hypovolemic patients should have volume status corrected before initiating diclofenac 1
• Hepatic dysfunction increases risk of adverse effects 1

Clinical Pitfalls to Avoid

• Do not assume topical diclofenac gel is safe in high-risk patients: systemic absorption occurs and upper GI hemorrhage has been documented even with cutaneous application 4
• Do not use diclofenac for perioperative pain management in elderly trauma patients, as NSAIDs are generally not recommended in this population 3
• Recognize aspirin-sensitive asthma: patients with chronic rhinosinusitis, nasal polyps, and severe bronchospasm have cross-reactivity with diclofenac 1

Safer Alternatives When Diclofenac is Contraindicated

• First-line alternatives: acetaminophen up to 4g daily, small doses of narcotics, or non-acetylated salicylates 2, 5
• If NSAID required: naproxen appears safest among NSAIDs with RR 0.92 for vascular events 2
• For localized pain: topical NSAIDs in elderly patients 2
• For moderate to severe pain: tramadol or opioid analgesics 3, 2