Why Daily Use of Voltaren (Diclofenac) Is Not Recommended
Daily use of Voltaren (diclofenac) carries significant cardiovascular and gastrointestinal risks that increase with duration of use, making it unsuitable for routine daily long-term therapy. 1, 2
Cardiovascular Risks That Increase With Daily Use
The FDA black box warning explicitly states that NSAIDs, including Voltaren, may cause serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal, and this risk increases with duration of use. 1, 2
Diclofenac demonstrates the highest cardiovascular risk among commonly used NSAIDs:
- Meta-analysis of randomized controlled trials shows diclofenac increases vascular events with a relative risk of 1.63 (95% CI 1.12-2.37) compared to placebo 1
- Registry data reveals even more concerning findings: recurrent MI risk of 1.54 (95% CI 1.23-1.93) and mortality risk of 2.40 (95% CI 2.09-2.80) 1
- These risks are comparable to or exceed those of rofecoxib (Vioxx), which was withdrawn from the market 1
The mechanism involves loss of protective COX-2 effects during myocardial ischemia, leading to larger infarct size, greater left ventricular wall thinning, and increased tendency to myocardial rupture. 1
Gastrointestinal Risks With Chronic Daily Use
NSAIDs cause serious gastrointestinal adverse events including inflammation, bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal and occur at any time during use without warning symptoms. 1, 2
The magnitude of this problem is substantial:
- 32,000 hospitalizations and 3,200 deaths annually in the United States from NSAID-related GI bleeding 1
- One-year risk of serious GI bleeding ranges from 1 in 2,100 in adults younger than 45 to 1 in 110 in adults older than 75 1
- Elderly patients are at particularly greater risk 1, 2
Renal Function Deterioration With Prolonged Use
Daily NSAID use can cause deterioration of renal function, particularly in patients who are elderly, volume-depleted, or have baseline renal impairment. 2 The FDA label specifically warns about monitoring for signs of worsening renal function during concomitant use with ACE inhibitors, ARBs, or diuretics. 2
Critical Drug Interactions That Worsen With Daily Use
Avoid NSAIDs including diclofenac when patients are taking anticoagulants, as they have a synergistic effect on bleeding risk. 2 Daily use compounds this risk exponentially. Additionally, NSAIDs should be avoided in patients taking apixaban or other anticoagulants, as they can worsen renal function and increase bleeding risk. 3
Recommended Duration Limits
For over-the-counter diclofenac potassium formulations, the maximum recommended treatment duration is 5 days for pain and 3 days for fever. 4 This reflects the understanding that short-term use minimizes cumulative cardiovascular and gastrointestinal risks while maintaining efficacy.
When Daily Use Might Be Considered (With Extreme Caution)
If daily diclofenac is absolutely necessary for chronic conditions:
- Use the lowest effective dose (minimum 0.3 mg/kg daily equivalent) 1
- Monitor CBC and chemistry profile periodically for GI bleeding, hepatotoxicity, and renal injury 2
- Assess cardiovascular risk factors before initiation—patients with cardiovascular disease or risk factors are at greater risk 1, 2
- Consider gastroprotection with proton pump inhibitors in high-risk patients 1
- Avoid in patients with history of NSAID-associated upper GI bleeding 1
Common Pitfalls to Avoid
- Never assume absence of dyspeptic symptoms means absence of serious ulceration—dyspeptic symptoms do not correlate well with clinically significant ulcerations 1
- Do not use concomitantly with other NSAIDs or salicylates—this increases gastrointestinal toxicity without increasing efficacy 2
- Avoid in patients requiring anticoagulation—the synergistic bleeding risk makes this combination particularly dangerous for daily use 2
- Do not use for perioperative pain in CABG surgery—this is an absolute contraindication 1, 2