Diclofenaco Guideline Summary

Indications and Usage

The American College of Rheumatology recommends diclofenac for the treatment of pain and inflammation in musculoskeletal conditions, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and acute musculoskeletal injuries 1, 2
Diclofenac topical is superior to placebo and equivalent to oral diclofenac for reducing pain in knee and hip osteoarthritis, with significantly fewer gastrointestinal adverse events 2
The American Heart Association suggests that diclofenac 100-150 mg/day is as effective as indomethacin or sulindac for ankylosing spondylitis 3
The World Health Organization recommends diclofenac as part of the first step of the analgesic ladder for cancer pain 5

The Mayo Clinic recommends a dosage of 100-150 mg/day for osteoarthritis and ankylosing spondylitis, or 150-200 mg/day for rheumatoid arthritis, administered in divided doses with food 2
The topical formulation of diclofenac has a favorable safety profile at 1 year, with fewer gastrointestinal adverse events compared to oral formulations 2, 4

The American Heart Association reports that diclofenac has the highest cardiovascular risk among non-selective NSAIDs, with a relative risk of 1.63 (95% CI: 1.12-2.37) for vascular events compared to placebo 6
The risk of recurrent myocardial infarction is increased, with a relative risk of 1.54 (95% CI: 1.23-1.93) in registry studies 6
Mortality risk is also increased, with a relative risk of 2.40 (95% CI: 2.09-2.80) compared to non-use 6

The American Gastroenterological Association recommends a protective strategy for patients with a history of symptomatic or complicated upper gastrointestinal ulcers, using a selective COX-2 inhibitor or a non-selective NSAID in combination with a proton pump inhibitor 1
The use of concomitant aspirin requires the use of a non-selective NSAID distinct from ibuprofen (such as diclofenac) in combination with a proton pump inhibitor, to avoid pharmacodynamic interactions that reduce the cardioprotective efficacy of aspirin 1

The National Kidney Foundation advises that oral NSAIDs should not be used in patients with stage IV or V chronic kidney disease (estimated glomerular filtration rate <30 mL/min) 1
The decision to use NSAIDs in patients with stage III chronic kidney disease (estimated glomerular filtration rate 30-59 mL/min) should be made on a case-by-case basis 1

The American Geriatrics Society prefers topical over oral diclofenac in elderly patients ≥75 years and those with increased risk of renal adverse events 4
Local adverse events are more common with topical NSAIDs than oral NSAIDs, but gastrointestinal events are significantly lower 2, 4