What concentration of diclofenac (Voltaren) gel is recommended for a middle-aged or older adult patient with a bone spur and no history of gastrointestinal or cardiovascular disease?

Diclofenac Gel Concentration for Bone Spur Pain

For a middle-aged or older adult with a bone spur and no gastrointestinal or cardiovascular contraindications, use diclofenac sodium 1% gel applied as 4 grams four times daily to the affected area. 1, 2

Primary Recommendation

• Diclofenac sodium 1% gel is the standard FDA-approved concentration for musculoskeletal pain, applied as 4 grams to the affected area four times daily for optimal pain relief 2, 3
• This concentration provides superior pain reduction compared to vehicle control, with a mean improvement of -5.3 points on the WOMAC pain scale in patients ≥65 years 2
• The 1% formulation achieves 5- to 17-fold lower systemic exposure compared to oral diclofenac, significantly reducing the risk of gastrointestinal, cardiovascular, and renal adverse events 4

Alternative Concentration Option

• Diclofenac sodium 2% topical solution applied twice daily is an alternative FDA-approved formulation that may improve adherence due to less frequent dosing 5
• The 2% solution demonstrated significant pain reduction (-4.4 points vs -3.4 points with vehicle, p=0.040) in a 4-week randomized controlled trial 5
• This twice-daily formulation may be preferred for patients who find four-times-daily application burdensome 5

Safety Profile in Your Patient Population

• In patients ≥65 years, the incidence of adverse events with diclofenac 1% gel (55.8%) was similar to younger patients (56.6%), with application site dermatitis being the most common treatment-related effect (5.8% vs 0.4% with vehicle) 2
• Gastrointestinal adverse events were infrequent and similar to vehicle rates in both age groups, making this an excellent choice for patients without GI disease 2
• Long-term safety data (up to 12 months) shows consistent tolerability in elderly patients and those with comorbidities including hypertension, diabetes, and cardiovascular disease 6
• The favorable safety profile at 1 year is consistent with 12-week data, with local skin reactions being generally mild and transient 1, 3

Application Instructions

• Apply 4 grams of diclofenac sodium 1% gel to the affected area four times daily (or 2% solution twice daily if using the alternative formulation) 2, 5
• Each application covers approximately 400 cm² of surface area 4
• Patients should apply >90% of scheduled doses for optimal efficacy 2
• Treatment duration should be limited to the shortest period necessary for symptom control, typically starting with 12 weeks and reassessing 2, 3

Expected Outcomes

• Significant pain reduction typically occurs within 1-7 days, with a mean reduction of 1.08 cm on a 10-cm visual analog scale compared to placebo 1
• Physical function improvement of 1.66 cm on a 10-cm scale compared to placebo can be expected 1
• Treatment satisfaction is significantly higher than placebo (OR 5.20,95% CI 2.03-13.33) 1

Critical Caveat

• While your patient has no history of cardiovascular disease, be aware that all NSAIDs (including topical formulations) carry a black box warning for increased risk of serious cardiovascular thrombotic events, though systemic exposure with topical diclofenac is markedly lower than oral formulations 7, 4
• Monitor for application site reactions (dermatitis, burning, rash, pruritus), which are the most common adverse events but generally mild 1, 2