What are the contraindications for Voltaren (diclofenac)?

Contraindications for Voltaren (Diclofenac)

Voltaren is absolutely contraindicated in patients with known hypersensitivity to diclofenac, 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 prior anaphylactic reactions or 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
• Previous serious skin reactions to NSAIDs, including Stevens-Johnson Syndrome, toxic epidermal necrolysis, or exfoliative dermatitis 1

Perioperative Setting

• In the setting of coronary artery bypass graft (CABG) surgery 1

Advanced Renal Disease

• Chronic kidney disease stage IV or V (eGFR <30 mL/min) is an absolute contraindication for daily diclofenac use 2

High-Risk Situations Requiring Avoidance

Cardiovascular Disease

• Patients with established ischemic heart disease or prior stroke should avoid diclofenac as first-line analgesia 2
• Diclofenac carries substantially elevated risks comparable to withdrawn drugs like rofecoxib, with mortality risk increasing 2.4-fold (RR 2.40,95% CI 2.09-2.80) and recurrent MI risk increasing 1.54-fold (RR 1.54,95% CI 1.23-1.93) in cardiac patients 2
• The mechanism involves high COX-2 inhibitory potency leading to loss of protective COX-2 upregulation during myocardial ischemia, resulting in larger infarct size 2

Severe Heart Failure

• Avoid diclofenac in patients with severe heart failure unless benefits clearly outweigh the risk of worsening heart failure 1
• NSAIDs demonstrate approximately two-fold increase in hospitalization for heart failure compared to placebo 1

Pregnancy

• Avoid use at approximately 30 weeks gestation and later due to risk of premature closure of fetal ductus arteriosus 1
• Use at about 20 weeks gestation or later may cause fetal renal dysfunction leading to oligohydramnios and neonatal renal impairment 1

Relative Contraindications and Extreme Caution Required

Gastrointestinal Risk Factors

• Patients with peptic ulcer disease within the past year require either COX-2 selective inhibitor plus proton pump inhibitor if NSAID use is unavoidable 2
• Age ≥75 years represents a relative contraindication; topical rather than oral NSAIDs should be used 2
• History of gastrointestinal ulceration or bleeding requires extreme caution, as higher doses carry increased risk 2

Renal Impairment

• Stage III CKD (eGFR 30-59 mL/min) requires careful risk-benefit assessment before use 2
• Patients with impaired renal function, dehydration, hypovolemia, or those taking diuretics and ACE inhibitors/ARBs are at greatest risk of renal decompensation 1

Anticoagulation Therapy

• Patients on anticoagulants face 3-6 fold increased bleeding risk and require extreme caution or complete avoidance 2
• If use is unavoidable, maximize non-NSAID analgesics, add proton pump inhibitor therapy, and monitor closely for bleeding 2

Aspirin-Sensitive Asthma

• Patients with aspirin-sensitive asthma (chronic rhinosinusitis with nasal polyps, severe bronchospasm, intolerance to aspirin/NSAIDs) are at risk of potentially fatal bronchospasm due to cross-reactivity 1

Critical Drug Interactions Requiring Avoidance or Extreme Caution

• ACE inhibitors and diuretics combined with diclofenac require extreme caution 2
• Antiplatelet agents combined with diclofenac significantly increase bleeding risk 2
• Diclofenac may blunt cardiovascular effects of antihypertensives, diuretics, ACE inhibitors, and ARBs 1

Common Pitfalls to Avoid

• Do not assume topical diclofenac is completely safe: systemic absorption occurs and has been documented to cause upper gastrointestinal hemorrhage, including massive bleeding requiring transfusions 3
• Do not prescribe for backache without excluding peptic ulcer disease, as two documented cases involved massive hemorrhage when backache was retrospectively attributable to peptic ulcer 3
• Do not use diclofenac for perioperative pain management in elderly trauma patients; consider tramadol or opioid analgesics instead 2