Can Voveran (Diclofenac) injection be given to patients with hypertension?

Voveran (Diclofenac) Injection Should Be Avoided or Used with Extreme Caution in Hypertensive Patients

NSAIDs including diclofenac can worsen blood pressure control and should be used with extreme caution in hypertensive patients, with blood pressure monitored closely during treatment. 1

Primary Concerns from FDA Drug Label

The FDA label for diclofenac explicitly warns that:

• NSAIDs can lead to onset of new hypertension or worsening of preexisting hypertension, either of which may contribute to increased cardiovascular events 1
• Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs 1
• Diclofenac should be used with caution in patients with hypertension, and blood pressure must be monitored closely during initiation and throughout the course of therapy 1
• NSAIDs increase the risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, with patients having known cardiovascular disease or risk factors at greater risk 1

Evidence from Clinical Guidelines

Major hypertension guidelines consistently recommend avoiding NSAIDs when possible:

• The ACC/AHA guidelines explicitly list NSAIDs as medications that may cause elevated blood pressure and recommend avoiding systemic NSAIDs when possible 2
• Alternative analgesics such as acetaminophen or tramadol should be considered depending on the indication 2
• The American Heart Association advises that blood pressure should be well-controlled (<140/90 mmHg) before considering NSAID therapy 3

Clinical Research Evidence

Recent high-quality research demonstrates the blood pressure effects of diclofenac:

• A 2021 comparative study found that while both NSAIDs raised blood pressure, etoricoxib caused significantly greater increases than diclofenac (mean systolic BP rise of 16.2 mmHg vs 8.5 mmHg, p=0.004) 4
• A 2017 Swedish cohort study of 5,463 hypertensive patients found that regular NSAID use did not significantly impair reaching target blood pressure, though naproxen showed a dose-response relationship with 7 mmHg systolic BP increase 5
• Older studies from 1991 showed that diclofenac did not significantly alter blood pressure control when combined with beta blockers, diuretics, or calcium channel blockers in controlled hypertensive patients 6, 7

Practical Clinical Algorithm

Step 1: Assess Blood Pressure Control

• If BP is uncontrolled (≥140/90 mmHg): Do not administer diclofenac injection 3
• If BP is severely elevated (≥160/100 mmHg): Absolutely contraindicated - address hypertension first 3
• If BP is well-controlled (<140/90 mmHg): May proceed with caution and close monitoring 3

Step 2: Consider Alternative Analgesics First

• Acetaminophen is the preferred first-line agent as it lacks significant blood pressure effects 3
• If stronger analgesia needed, carefully titrated opioids may be safer than NSAIDs in patients with severe hypertension 3
• Topical NSAIDs can be considered as they have less systemic effect 2

Step 3: If Diclofenac Must Be Used

• Use the lowest effective dose for the shortest duration possible 1
• Monitor blood pressure closely during initiation and throughout therapy 1
• Check blood pressure within 3-7 days of starting treatment 2
• Assess for signs of fluid retention or worsening heart failure 1

Step 4: Special Precautions

• Patients on antiplatelet or anticoagulant therapy with uncontrolled hypertension require immediate BP lowering to reduce hemorrhagic stroke risk 3
• Elderly patients and those with cardiovascular disease are at highest risk for adverse events 1
• Patients with renal impairment require additional caution as NSAIDs can precipitate renal decompensation 1

Critical Pitfalls to Avoid

• Never assume that because BP is currently controlled, diclofenac is safe - it can destabilize previously controlled hypertension 1
• Do not use diclofenac in patients with resistant hypertension requiring multiple agents, as it may counteract antihypertensive therapy 2
• Avoid prolonged courses - the cardiovascular risk increases with duration of therapy 1
• Do not ignore the interaction with diuretics, which may become less effective 1

Bottom Line

For acute pain management in hypertensive patients, acetaminophen or carefully titrated opioids are safer alternatives to diclofenac injection. 3 If diclofenac must be used, blood pressure must be well-controlled beforehand, the lowest dose should be used for the shortest duration, and close BP monitoring is mandatory throughout treatment. 1