Diclofenac and Cardiovascular Risk

Introduction to Diclofenac

Diclofenac is a nonselective NSAID with preferential COX-2 inhibitory activity, inhibiting both cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) enzymes, but demonstrates relatively greater COX-2 selectivity compared to many traditional NSAIDs 1
It lies on the "more COX-2-selective end of the spectrum of COX inhibition" 1

Diclofenac's preferential COX-2 inhibition contributes to its increased cardiovascular risk compared to less COX-2 selective NSAIDs 1
The American Heart Association notes that diclofenac has been associated with an increased risk of thrombotic events 2
In a large registry study, diclofenac was associated with a hazard ratio of 2.40 (95% CI 2.09-2.80) for mortality in patients with prior myocardial infarction 3
The FDA requires a black box warning on diclofenac's label regarding cardiovascular thrombotic risk 1

The American College of Cardiology/American Heart Association guidelines recommend against using NSAIDs with increasing degrees of COX-2 selectivity in patients with STEMI 3
For patients requiring pain relief who have cardiovascular risk factors, a stepped-care approach is recommended, starting with acetaminophen, small doses of narcotics, or non-acetylated salicylates before considering NSAIDs 3

Be aware that diclofenac's COX-2 selectivity contributes to its cardiovascular risk profile, which is higher than some other NSAIDs like naproxen 1
For patients with cardiovascular disease, diclofenac should not be among the first choices for pain relief 1
Use the lowest effective dose for the shortest possible duration to minimize risks 3
Consider the patient's individual cardiovascular risk profile when selecting an NSAID 2