Voltaren (Diclofenac) Dosage and Treatment Guidelines
Oral Formulations
For oral diclofenac, the FDA-approved dosing is 50 mg three times daily for acute pain or primary dysmenorrhea, with a maximum of 150-200 mg/day in divided doses depending on the condition being treated. 1
Standard Dosing by Indication
Acute Pain and Primary Dysmenorrhea:
- Initial dose: 50 mg three times daily 1
- Alternative regimen: 100 mg initial dose followed by 50 mg doses may provide better relief in some patients 1
- Over-the-counter formulation (diclofenac potassium 12.5 mg): Initial dose of 2 tablets (25 mg), then 1-2 tablets every 4-6 hours, maximum 6 tablets daily (75 mg/day) 2
Osteoarthritis:
- Recommended dose: 100-150 mg/day in divided doses 1
- Typical regimen: 50 mg twice or three times daily 1
- Alternative: 150 mg once daily as prolonged-release formulation 3
Rheumatoid Arthritis:
- Recommended dose: 150-200 mg/day in divided doses 1
- Typical regimen: 50 mg three or four times daily 1
Degenerative Arthritis (Step-Therapy Approach):
- Diclofenac should be considered only after paracetamol (up to 4 g daily) and ibuprofen (1.2-2.4 g daily) have failed 4
- When used, diclofenac is comparable to naproxen as an alternative NSAID 4
Critical Formulation Note
Different diclofenac formulations (enteric-coated, extended-release, immediate-release) are NOT bioequivalent even at the same milligram strength. 1 Do not substitute formulations without adjusting dosing.
Injectable Formulations
For injectable diclofenac, the maximum daily dose is 150 mg administered as 75 mg every 12 hours, with intramuscular administration preferred over intravenous in most clinical settings. 5
Dosing Guidelines
Intramuscular Administration:
- Standard dose: 75 mg per injection 5
- Minimum interval between doses: 12 hours 5
- Maximum daily dose: 150 mg (two 75 mg doses) 5
- Preferred route over IV due to lower risk of dilution and dosing errors 5
Intravenous Administration:
- Same maximum daily dose as IM: 150 mg/day 5
- Typical regimen: 75 mg every 12 hours 5
- Reserved for severe cases not responding to IM or hospital settings with appropriate monitoring 5
- Postoperative pain: 18.75-37.5 mg boluses every 6 hours (significantly reduces opioid requirements) 5
Acute Crystal-Induced Arthritis:
- 150 mg daily for first 3 days, then 75 mg daily for 3 additional days 5
Acute Renal Colic:
- Single IM dose of 75 mg as first-line treatment 5
Topical Formulations
For localized pain, topical diclofenac gel or patch can be used as adjunctive therapy with lower systemic absorption. 4
- Diclofenac gel: Apply 3 times daily to painful site 4
- Diclofenac patch (180 mg): One patch daily or twice daily 4
- Minimal systemic absorption compared to oral/injectable routes 4
Safety Considerations and Monitoring
Gastrointestinal Risk
Diclofenac carries intermediate GI risk—higher than ibuprofen but lower than azapropazone—with risk increasing at higher doses. 4
- High-dose diclofenac (150 mg/day oral) may have similar GI risk to intermediate-risk NSAIDs 4
- Absolute contraindication: Active peptic ulcer disease 5
- Extreme caution needed: History of peptic ulcer, age >60 years, concomitant anticoagulants 5
Cardiovascular and Renal Risk
Higher doses increase cardiovascular and renal toxicity without additional analgesic benefit. 5
- Never exceed 150 mg/day by any route 5
- Use with extreme caution in pre-existing cardiovascular disease, compromised fluid status, or concomitant nephrotoxic drugs 5
Drug Interactions
Concomitant use with anticoagulants increases bleeding risk 3-6 fold. 5
Monitoring Requirements for Chronic Therapy
For patients on chronic NSAID therapy (>3 months), monitor the following every 3 months: 5
- Blood pressure
- BUN and creatinine (discontinue if doubled)
- Liver function tests (discontinue if >3× upper limit of normal)
- Complete blood count
- Fecal occult blood
Renal Impairment
- Consider dose reduction if creatinine clearance <10 mL/min 5
- Discontinue if BUN or creatinine doubles 5
Treatment Duration and Alternatives
If two NSAIDs (including diclofenac) are tried sequentially without efficacy, switch to an alternative analgesic approach rather than trialing additional NSAIDs. 5
- Consider opioid analgesics as safe and effective alternatives 5
- Consider non-pharmacologic interventions (nerve blocks, physical therapy, radiotherapy for cancer pain) 5
For OTC diclofenac potassium, maximum treatment duration is 5 days for pain and 3 days for fever. 2
Common Pitfalls to Avoid
- Do not exceed 150 mg/day total dose regardless of route or formulation 5, 1
- Do not combine different formulations without accounting for total daily dose 1
- Do not use in active peptic ulcer disease under any circumstances 5
- Do not combine with anticoagulants without intensive monitoring 5
- Do not use IV route routinely—reserve for hospital settings with monitoring 5
- Do not continue trialing NSAIDs if two have already failed—switch therapeutic approach 5