What is the recommended dose of Diclofenac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) for an adult patient, likely over 50 years old, with osteoarthritis (OA) of the right wrist and no significant medical history?

Diclofenac Dosing for Wrist Osteoarthritis

For osteoarthritis of the wrist, start with topical diclofenac gel applied to the affected joint as first-line pharmacological therapy, and only consider oral diclofenac 100-150 mg/day in divided doses (50 mg twice or three times daily) if topical treatment provides insufficient relief after an adequate trial. 1, 2

Treatment Algorithm for Wrist OA

First-Line Approach: Topical Therapy

• Topical diclofenac gel is the preferred initial pharmacological treatment for hand/wrist OA because it provides effective local analgesia with markedly reduced systemic exposure compared to oral NSAIDs 1, 3
• Apply topical diclofenac to the affected wrist joint before considering oral NSAIDs, as this approach minimizes gastrointestinal, cardiovascular, and renal toxicity risks 1, 4
• Topical NSAIDs showed small but significant improvements in pain and function after 8 weeks in high-quality studies, with similar efficacy to oral NSAIDs but superior safety 1, 5

Second-Line: Oral Diclofenac Dosing

If topical treatment is insufficient after an adequate trial (typically 2-8 weeks), transition to oral therapy:

• Standard oral diclofenac dose for OA: 100-150 mg/day in divided doses 2
  • 50 mg twice daily (100 mg total), OR
  • 50 mg three times daily (150 mg total) 2
• Use the lowest effective dose for the shortest duration necessary 1, 2
• Prescribe for a limited duration, preferably on-demand rather than continuous use 1

Important Dosing Considerations

• Different diclofenac formulations (enteric-coated, extended-release, immediate-release) are not bioequivalent even at the same milligram strength 2
• Low-dose submicron diclofenac 35 mg three times daily (105 mg total) has shown efficacy in OA with potentially improved tolerability, though this formulation may not be universally available 6, 7
• Re-evaluate the patient's requirements and response periodically, adjusting dose and frequency to individual needs 1, 2

Critical Safety Precautions

Gastroprotection Requirements

• Co-prescribe a proton pump inhibitor with oral diclofenac in patients over 50 years old, as age is a significant gastrointestinal risk factor 1, 8
• Additional GI risk factors requiring gastroprotection include: history of GI bleeding, concurrent low-dose aspirin use, or other ulcer risk factors 1, 8

Cardiovascular and Renal Monitoring

• Assess cardiovascular risk factors before prescribing oral NSAIDs; use with extreme caution in patients with hypertension, cardiovascular disease, or cerebrovascular disease 1
• Monitor renal function, especially in elderly patients or those with chronic kidney disease 1, 8
• All oral NSAIDs, including diclofenac, carry potential cardiovascular and renal toxicity that increases with dose and duration 1

Common Pitfalls to Avoid

• Never combine topical and oral diclofenac (or any NSAIDs), as this increases adverse event risk without additional benefit 3, 4
• Do not prescribe oral diclofenac without first trying topical formulations, unless multiple joints are affected making topical application impractical 1
• Avoid prescribing oral NSAIDs without gastroprotection in patients over 50 years old 1, 8
• Do not continue oral NSAID therapy indefinitely without periodic reassessment of ongoing benefit versus risk 1, 3
• Be aware that even topical NSAIDs may have systemic effects in patients taking low-dose aspirin for cardioprotection 3

When Systemic Therapy is Preferred

Oral diclofenac may be preferred over topical when:

• A large number of joints are affected, making topical application impractical 1
• The patient has failed an adequate trial of topical therapy (typically 2-8 weeks) 1, 5
• Severe pain requires more aggressive systemic analgesia 1