What are alternative topical pain relievers to Voltaren (diclofenac) for a patient with musculoskeletal pain conditions, such as osteoarthritis or rheumatoid arthritis?

Alternative Topical Pain Relievers to Voltaren (Diclofenac)

For musculoskeletal pain conditions like osteoarthritis, topical ketoprofen gel and capsaicin are the primary evidence-based alternatives to topical diclofenac, while topical NSAIDs should not be used for deep joints like the hip. 1

Topical NSAID Alternatives

Ketoprofen Gel

• Ketoprofen gel is the strongest alternative topical NSAID to diclofenac, with moderate-quality evidence showing 63% of patients achieve significant pain relief versus 48% with placebo over 6-12 weeks in chronic musculoskeletal pain (NNT 6.9) 1, 2
• For acute musculoskeletal injuries (strains/sprains), ketoprofen gel provides 72% pain relief versus 33% with placebo at 7 days (NNT 2.5), making it highly effective for acute conditions 3
• Apply ketoprofen gel to affected areas 3-4 times daily for hand and knee osteoarthritis 1, 2

Ibuprofen Topical Preparations

• Topical ibuprofen gels and creams have limited evidence but may provide benefit for localized musculoskeletal pain 3
• FDA-approved oral ibuprofen is indicated for osteoarthritis and rheumatoid arthritis when topical formulations are insufficient 4

Non-NSAID Topical Alternatives

Capsaicin

• Topical capsaicin is effective for chronic osteoarthritis and neuropathic pain, with EULAR guidelines specifically recommending it for hand osteoarthritis (NNT 3 for clinical improvement at 4 weeks) 1
• Apply capsaicin 0.025% to 0.075% cream 3-4 times daily to affected areas, with therapeutic effects requiring 2-4 weeks of continuous application as substance P depletion occurs gradually 5, 6
• High-concentration capsaicin 8% has moderate evidence for postherpetic neuralgia (NNT 11) but is not appropriate for acute injuries 1, 3
• Critical caveat: Initial burning/stinging is expected and typically diminishes with continued use; counsel patients to apply consistently to avoid therapeutic failure 5
• Local adverse events occur in 63% of patients (mostly mild skin reactions) compared to placebo, but serious systemic effects are rare 3

Lidocaine Patches

• Topical lidocaine has limited evidence for osteoarthritis specifically, though it shows efficacy for neuropathic pain conditions like postherpetic neuralgia 1, 6
• The CDC guidelines note insufficient evidence for topical lidocaine in chronic musculoskeletal pain 1

Critical Anatomical Considerations

Deep Joint Limitations

• Topical agents should NOT be used for hip osteoarthritis due to inadequate drug penetration to the deep hip joint 7
• The American College of Rheumatology specifically recommends against topical agents for hip OA, favoring oral NSAIDs or acetaminophen instead 7
• Topical NSAIDs are most effective for superficial joints (knee, hand) where drug penetration is adequate 1

Oral Alternatives When Topical Therapy Insufficient

First-Line Oral Options

• Oral NSAIDs (particularly ibuprofen at lowest effective dose) are the most cost-effective alternative when topical therapy fails, with FDA approval for osteoarthritis and rheumatoid arthritis 1, 4
• Acetaminophen up to 4g/day is recommended as first-line oral therapy, though it has limited effectiveness compared to NSAIDs and is no longer considered first-line for osteoarthritis 1, 8
• The CDC 2022 guidelines note that oral NSAIDs have small to moderate benefits for osteoarthritis pain at 3-6 months 1

Safety Considerations for Oral NSAIDs

• Use oral NSAIDs at the lowest effective dosage and shortest duration necessary, as risks increase with longer use and higher dosages 1
• Exercise caution in older adults and patients with cardiovascular comorbidities, chronic renal failure, or previous gastrointestinal bleeding 1
• For patients with gastrointestinal risk, consider cyclooxygenase-2 inhibitors or NSAIDs with proton pump inhibitors 1

Practical Treatment Algorithm

For hand/knee osteoarthritis:

1. Start with topical ketoprofen gel or topical diclofenac (if not contraindicated) applied 3-4 times daily 1, 2
2. If topical NSAIDs insufficient after 2-4 weeks, add capsaicin 0.025-0.075% cream (requires 2-4 weeks for full effect) 1, 5
3. If topical therapy inadequate, transition to oral ibuprofen or oral NSAIDs at lowest effective dose 1, 4

For hip osteoarthritis:

1. Skip topical agents entirely due to inadequate penetration 7
2. Start with oral NSAIDs as first-line pharmacotherapy 7
3. Consider acetaminophen only if NSAIDs contraindicated 7

For acute musculoskeletal injuries (sprains/strains):

1. Use topical ketoprofen gel or topical diclofenac for immediate anti-inflammatory effects 9, 3
2. Do NOT use capsaicin for acute injuries—evidence is exclusively for chronic pain conditions 9
3. Over-the-counter menthol/camphor preparations provide immediate counter-irritant relief as adjunct 9

Common Pitfalls to Avoid

• Do not use capsaicin for acute injuries—its mechanism requires weeks to work and evidence base is exclusively for chronic pain lasting months to years 9
• Avoid topical agents for hip osteoarthritis—the joint depth prevents adequate drug penetration 7
• Do not discontinue capsaicin prematurely due to initial burning sensation; therapeutic effects require 2-4 weeks of consistent application 5, 9
• Modified-release NSAID preparations are more expensive with no evidence of superior effectiveness and should not be used 1
• Topical NSAIDs in acute pain do not increase systemic or local adverse events compared to placebo (4.3% vs 4.6%), making them safer than oral alternatives 3