Is it safe for a 70-year-old female with impaired renal function (GFR 36, creatinine 1.55) to use Valtaren (diclofenac) gel?

From the Guidelines

Valtaren gel (diclofenac sodium) should be used with extreme caution in this 70-year-old female with reduced kidney function (GFR 36, creatinine 1.55), as it may worsen her renal function, and alternative pain management strategies should be considered. According to the study on NSAID prescribing precautions 1, impaired renal function is a significant concern when using NSAIDs, and it is recommended to avoid NSAIDs in persons with renal disease or use them with caution when combining with other medications that potentially decrease renal function.

Some key points to consider when using Valtaren gel in this patient include:

• The patient's moderate kidney impairment (GFR 36) increases the risk of worsening renal function with NSAID use 1
• Topical NSAIDs like Valtaren gel have less systemic absorption compared to oral NSAIDs, but some absorption still occurs and could affect kidney function
• The patient should be monitored for worsening kidney function, especially if using the gel regularly or over large areas
• Alternative pain management strategies such as acetaminophen or physical therapy might be preferable for long-term use in this patient with compromised kidney function

It is essential to weigh the potential benefits of using Valtaren gel against the potential risks, particularly the risk of worsening renal function, and to consider alternative pain management strategies that may be safer for this patient. The patient should stay well-hydrated and report any symptoms like decreased urination, swelling, or unexplained weight gain. If Valtaren gel is used, it would be reasonable to use the gel at the lowest effective dose, over the smallest possible area, and for the shortest duration needed to control symptoms.

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.
• Elderly patients are at greater risk for NSAID-associated serious renal adverse reactions.
• 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 in this patient should be carefully weighed against the potential risk of worsening renal function. Given the patient's renal impairment and age, it is recommended to exercise caution when using diclofenac sodium topical solution and to monitor renal function closely. 2

From the Research

Safety of Valtaren Gel for a 70-year-old Female with GFR 36 and Creatinine 1.55

• The patient's condition involves chronic kidney disease (CKD) with a glomerular filtration rate (GFR) of 36 and creatinine level of 1.55, indicating impaired renal function.
• Valtaren gel contains diclofenac, a nonsteroidal anti-inflammatory drug (NSAID), which can pose risks for patients with CKD due to its potential for nephrotoxicity 3.
• However, a study suggests that diclofenac may be well tolerated in patients with renal impairment when used at the lowest effective dose for the shortest duration 4.
• Another study emphasizes the importance of cautious use of NSAIDs in patients with CKD, considering factors such as the level of GFR and the presence of comorbid conditions 3.
• The use of NSAIDs, including diclofenac, in patients with CKD requires careful evaluation of the benefits and risks, as well as consideration of alternative analgesics 5, 3.
• There is limited information specifically on the use of Valtaren gel in patients with CKD, but the general principles of NSAID use in this population can be applied 4, 3.
• It is essential to monitor the patient's renal function and adjust the dosage or discontinue the use of Valtaren gel if any adverse effects occur 5, 3.