Can a 70-year-old patient with impaired renal function (GFR 36) and elevated serum creatinine (1.55) use Voltaren (diclofenac) gel for shoulder pain?

From the FDA Drug Label

1. 6 Renal Toxicity and Hyperkalemia Renal Toxicity Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. Renal toxicity has also been seen in patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion In these patients, administration of an NSAID may cause a dose-dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decompensation Patients at greatest risk of this reaction are those with impaired renal function, dehydration, hypovolemia, heart failure, liver dysfunction, those taking diuretics and ACE-inhibitors or ARBs, and the elderly. Discontinuation of NSAID therapy is usually followed by recovery to the pretreatment state No information is available from controlled clinical studies regarding the use of diclofenac sodium topical solution in patients with advanced renal disease. The renal effects of diclofenac sodium topical solution may hasten the progression of renal dysfunction in patients with preexisting renal disease Correct volume status in dehydrated or hypovolemic patients prior to initiating diclofenac sodium topical solution. Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia during use of diclofenac sodium topical solution [ see Drug Interactions ( 7) ] Avoid the use of diclofenac sodium topical solution in patients with advanced renal disease unless the benefits are expected to outweigh the risk of worsening renal function. If diclofenac sodium topical solution is used in patients with advanced renal disease, monitor patients for signs of worsening renal function

The patient has a GFR of 36 and creatinine of 1.55, indicating impaired renal function.

• The use of diclofenac sodium topical solution may cause a dose-dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decompensation in patients with impaired renal function.
• The patient is at greater risk of renal toxicity due to their impaired renal function and age (70 years).
• It is recommended to monitor renal function in patients with renal impairment during use of diclofenac sodium topical solution.
• The benefits of using diclofenac sodium topical solution should be weighed against the risk of worsening renal function in this patient. Given the patient's renal impairment, it is recommended to use diclofenac sodium topical solution with caution and monitor renal function closely. However, the decision to use this medication should be made on a case-by-case basis, considering the potential benefits and risks. 1

From the Research

The 70-year-old patient with reduced kidney function (GFR 36, creatinine 1.55) can use Voltaren gel for shoulder pain, but with caution and close monitoring. The patient should apply it sparingly (no more than 4 grams per application), limit application to 2-4 times daily, use it for the shortest duration necessary, and avoid covering large areas of skin. According to a recent study 2, diclofenac may be well tolerated in patients with mild to moderate chronic kidney disease (CKD) when used at the lowest effective dose for the shortest duration. However, it's essential to monitor the patient for worsening kidney function, fluid retention, or increased blood pressure during treatment. Topical diclofenac is preferred over oral NSAIDs in patients with kidney impairment because approximately 6-10% of the applied dose is absorbed systemically, making it less likely to further damage the kidneys. Alternative pain management options like physical therapy should also be considered, as acetaminophen may also increase the risk of renal impairment 3. It's crucial to weigh the benefits and risks of using Voltaren gel in this patient and to closely monitor their kidney function and overall health. The patient's kidney function and other health parameters should be regularly assessed to minimize the risk of adverse effects. In general, the use of NSAIDs, including topical diclofenac, requires careful consideration in patients with kidney disease, and the patient should be informed of the potential risks and benefits. The study by 2 provides the most recent and relevant guidance on the use of diclofenac in patients with CKD, and its findings should be taken into account when making treatment decisions. Ultimately, the decision to use Voltaren gel in this patient should be based on a thorough evaluation of their individual needs and health status. Key considerations include:

• Close monitoring of kidney function and other health parameters
• Use of the lowest effective dose for the shortest duration necessary
• Avoidance of covering large areas of skin and limiting application to 2-4 times daily
• Consideration of alternative pain management options, such as physical therapy
• Regular assessment of the patient's kidney function and overall health to minimize the risk of adverse effects.