Is Voltaren (diclofenac) safe for hip pain in an adult with no significant medical history?

Can You Use Voltaren on Hip?

Yes, you can use Voltaren (diclofenac) for hip pain, but oral formulations are strongly preferred over topical gel because the hip joint is too deep for topical agents to penetrate effectively.

Oral Diclofenac for Hip Pain

Oral NSAIDs including diclofenac are proven effective for hip osteoarthritis and should be your first-line pharmacological choice at the lowest effective dose for the shortest duration. 1

Dosing for Hip Pain

• Standard oral dose: 75-150 mg daily in divided doses 1, 2
• Use the lowest effective dosage for shortest duration consistent with treatment goals 3
• Diclofenac has demonstrated superior pain relief and improved joint mobility compared to naproxen in hip osteoarthritis 4, 5

Gastrointestinal Protection Strategy

• Add gastroprotective agents (PPIs, misoprostol, or double-dose H2 blockers) if GI risk factors are present 2
• Be aware of dose-dependent GI bleeding risk: OR 2.2 for 75mg, OR 3.2 for 75-150mg, and OR 12.2 for >150mg daily 2
• Upper GI ulcers, bleeding, or perforation occur in approximately 1% of patients treated for 3-6 months and 2-4% treated for one year 3

Topical Diclofenac Gel for Hip Pain

Topical diclofenac gel has insufficient evidence for hip pain and is unlikely to provide meaningful benefit due to the depth of the hip joint. 2

Why Topical Formulations Are Problematic for Hip

• The VA/DoD 2020 guidelines found insufficient evidence to recommend for or against topical pharmacotherapy for hip pain, specifically noting that given the depth of the hip joint, it is unlikely a topical agent would provide much benefit 2
• All high-quality evidence supporting topical diclofenac efficacy comes from knee osteoarthritis studies only 2
• The FDA-approved topical solution is specifically indicated for knee osteoarthritis, not hip 3

If You Proceed with Topical Despite Limited Evidence

• Theoretical dosing would be 4 grams of gel per hip, applied 3 times daily (24 grams daily for both hips) 2
• Apply to clean, dry skin and avoid showering/bathing for at least 30 minutes after application 3
• Wash hands after use and wait until area is completely dry before covering with clothing 3

Multimodal Pain Management Approach

For acute hip pain or trauma, implement multimodal analgesia starting with NSAIDs (if not contraindicated) combined with acetaminophen. 1, 6

• Intravenous acetaminophen every 6 hours is recommended as first-line treatment in acute trauma pain 1
• NSAIDs can be added for severe pain, taking into account potential adverse events and drug interactions 1
• Opioids should be reserved only for breakthrough pain at the lowest effective dose for the shortest period 1
• For hip fractures specifically, peripheral nerve blocks at presentation reduce preoperative and postoperative opioid requirements 1

Critical Safety Monitoring

Cardiovascular Risk

• Avoid diclofenac in patients with recent MI unless benefits outweigh risks of recurrent CV thrombotic events 3
• The incidence of death in the first year post-MI was 20 per 100 person-years in NSAID-treated patients compared to 12 per 100 person-years in non-NSAID exposed patients 3

Hepatotoxicity Monitoring

• Measure transaminases at baseline and within 4-8 weeks after initiating treatment, then periodically during long-term therapy 3
• Meaningful elevations (>3 times ULN) of AST occurred in about 2% of patients in clinical trials 3
• Discontinue immediately if abnormal liver tests persist or worsen, or if clinical signs of liver disease develop 3

Renal Function

• Assess renal function before initiating therapy, particularly in elderly patients 2

Common Pitfalls to Avoid

• Do not combine topical and oral NSAIDs unless benefit outweighs risk, and conduct periodic laboratory evaluations if combination therapy is used 3
• Do not apply topical formulations to open wounds or use with occlusive dressings 3
• Avoid use in pregnancy after gestational week 28 due to risks of oligohydramnios and fetal ductus arteriosus complications 7
• Be aware that one rare case report from 1987 suggested NSAIDs including diclofenac may be associated with avascular necrosis of the femoral head, though this is extremely uncommon 8

Evidence for Tissue Penetration

• Oral diclofenac achieves therapeutic concentrations in articular cartilage, synovial membrane, and bone of the hip joint after 5 days of therapy with Voltaren SR 75mg twice daily 9
• This tissue penetration supports the use of oral formulations for hip pathology 9