What are the alternatives to oral Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) or acetaminophen (Tylenol) for a patient who can use Voltaren (Diclofenac) gel?

From the Guidelines

Voltaren gel is a safe and effective option for pain relief even when oral NSAIDs or Tylenol cannot be used. According to a 2020 clinical guideline from the American College of Physicians and American Academy of Family Physicians, published in the Annals of Internal Medicine 1, topical NSAIDs, such as Voltaren gel, have been shown to improve symptom relief in patients with acute pain from non-low back, musculoskeletal injuries. The guideline states that topical NSAIDs alone or plus menthol gel had a significant improvement in symptom relief compared to placebo, with an odds ratio of 6.39 [CI, 3.48 to 11.75] for topical NSAIDs and 13.34 [CI, 3.30 to 53.92] for topical NSAIDs plus menthol gel.

When using Voltaren gel, it is essential to follow the recommended application guidelines:

• Apply a thin layer of the gel to the affected area
• Gently rub it in until absorbed
• Typically apply 2-4 times daily, depending on the specific formulation
• Standard dose is 2-4 grams per application (about the size of a quarter to a half-dollar coin) It is also important to note that Voltaren gel works locally, with minimal absorption into the bloodstream, making it a suitable option for those who cannot take oral NSAIDs or Tylenol. However, it is crucial to follow proper application and precautions, such as:
• Washing hands after application (unless treating your hands)
• Avoiding application to broken or irritated skin
• Not covering the area with tight bandages If skin irritation occurs or pain persists beyond 7-10 days, it is recommended to consult a healthcare provider. The guideline highlights the effectiveness of topical NSAIDs, including Voltaren gel, for pain reduction, improvement in function, and treatment satisfaction, making it a valuable option for patients who cannot use oral pain medications 1.

From the Research

Alternatives to Oral NSAIDs and Tylenol

• Topical therapies, such as capsaicin and topical diclofenac, have been shown to be effective in the treatment of patients with chronic pain, particularly for those who cannot take oral NSAIDs or Tylenol 2.
• Topical NSAIDs, including diclofenac and ketoprofen, have been found to provide relief superior to that of placebo and comparable to that of oral ibuprofen in patients with knee osteoarthritis 2, 3.
• The use of topical NSAIDs may offer a safe, well-tolerated, and effective alternative to systemic therapies in the treatment of patients with chronic, localized musculoskeletal and neuropathic pain 2, 4.

Efficacy of Topical NSAIDs

• Studies have demonstrated that topical diclofenac, ibuprofen, ketoprofen, piroxicam, and indomethacin are effective in providing pain relief in acute musculoskeletal conditions, with some formulations having a lower number needed to treat (NNT) for clinical success 5.
• The Emulgel formulation of diclofenac had the lowest NNT of 1.8, indicating high efficacy in providing pain relief 5.
• Topical NSAIDs have been found to have a similar efficacy to oral NSAIDs in treating acute and chronic injuries, with fewer gastrointestinal side effects 4.

Safety of Topical NSAIDs

• Local skin reactions were generally mild and transient, and did not differ from placebo, with high-quality data indicating minimal adverse events 5.
• Systemic adverse events were rare, and withdrawals due to adverse events were low, with low-quality data indicating minimal risk 5.
• The use of topical NSAIDs may be associated with fewer serious adverse events, particularly gastrointestinal reactions, compared to oral NSAIDs 4.