Is Voltaren (diclofenac) safe to use in patients with Chronic Kidney Disease (CKD)?

Is Voltaren (Diclofenac) Safe in CKD?

No, Voltaren (diclofenac) is generally not safe in CKD and should be avoided, particularly in patients with advanced renal disease (CKD stages 4-5 with eGFR <30 mL/min), where it is contraindicated. 1, 2

Contraindications and Strong Warnings

Oral NSAIDs, including diclofenac, should not be used in patients with CKD stage IV or V (eGFR <30 mL/min). 1 The FDA labeling explicitly states to avoid the use of diclofenac in patients with advanced renal disease unless the benefits are expected to outweigh the risk of worsening renal function. 2

• Even in CKD stage III (eGFR 30-59 mL/min), the decision to use diclofenac should be made only after careful consideration of benefits versus risks on an individual basis. 1
• The KDIGO guidelines emphasize avoiding NSAIDs in CKD patients, particularly when combined with RAAS inhibitors (ACE inhibitors or ARBs), due to significantly increased risk of acute kidney injury and hyperkalemia. 3

Mechanisms of Nephrotoxicity in CKD

Diclofenac causes dose-dependent reduction in prostaglandin formation, which secondarily reduces renal blood flow and may precipitate overt renal decompensation. 2

• Patients at greatest risk include those with impaired renal function, dehydration, hypovolemia, heart failure, liver dysfunction, those taking diuretics and ACE inhibitors or ARBs, and the elderly. 2
• The renal effects of diclofenac may hasten the progression of renal dysfunction in patients with preexisting renal disease. 2
• Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. 2

Additional Risks Specific to CKD

Hyperkalemia risk is substantially elevated: Increases in serum potassium concentration, including hyperkalemia, have been reported with NSAIDs even in patients without renal impairment, attributed to a hyporeninemic-hypoaldosteronism state. 2

• The combination of NSAIDs with ACE inhibitors or ARBs significantly increases the risk of acute kidney injury and hyperkalemia, especially when diuretics are also used. 3
• Patients should be educated to avoid NSAIDs when on RAAS inhibitors. 1

Cardiovascular complications: Diclofenac may blunt the cardiovascular effects of therapeutic agents used to treat hypertension and heart failure (diuretics, ACE inhibitors, ARBs). 2

Evidence from Clinical Studies

A retrospective population study found that 49.8% of CKD patients received at least one prescription for a contraindicated nephrotoxic drug, with diclofenac being among the most frequently prescribed (11.0%), and 35.6% of CKD patients were treated with NSAIDs for periods exceeding 90 days. 4

• Experimental evidence demonstrates that even a single oral dose of diclofenac in the setting of pre-existing subclinical acute kidney injury can cause progression to chronic kidney disease. 5
• The incidence of diclofenac/acetaminophen combination-induced acute kidney injury in postoperative pain relief was 7.7%, with patients having hypertension or liver cirrhosis being more likely to develop AKI. 6

Monitoring Requirements If Use Is Unavoidable

If diclofenac must be used despite CKD (which should be rare and only after exhausting alternatives):

• Correct volume status in dehydrated or hypovolemic patients prior to initiating diclofenac. 2
• Monitor renal function (serum creatinine and eGFR) within 2-4 weeks of initiation or dose changes. 3
• Monitor serum potassium levels within 2-4 weeks of initiation or dose changes. 3
• Discontinue if creatinine increases >30% from baseline. 3
• Use the lowest effective dose for the shortest duration possible. 2
• Monitor for signs of worsening renal function continuously. 2

Safer Alternatives for Pain Management in CKD

For acute pain conditions like gout in CKD patients, low-dose colchicine or intra-articular/oral glucocorticoids are preferable to NSAIDs. 3

• For chronic pain in CKD patients who have not responded to other modalities, opioid analgesics may be considered with appropriate monitoring and risk stratification. 1
• Acetaminophen at appropriate doses may be considered, though combination with diclofenac increases AKI risk. 6

Critical Pitfalls to Avoid

Never combine diclofenac with ACE inhibitors, ARBs, or diuretics in CKD patients without extreme caution and close monitoring, as this combination dramatically increases the risk of acute kidney injury and hyperkalemia. 1, 3, 2

• Do not assume that short-term use is safe—even single doses can cause progression to chronic kidney disease in vulnerable patients. 5
• CKD diagnosis should prompt immediate discontinuation or avoidance of diclofenac prescriptions. 4