Diclofenac is risky, don't use.

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101N

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http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001388

Conclusions

Listing of NSAIDs on national EMLs should take account of cardiovascular risk, with preference given to low risk drugs. Diclofenac has a risk very similar to rofecoxib, which was withdrawn from worldwide markets owing to cardiovascular toxicity. Diclofenac should be removed from EMLs.
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101N said:
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001388

Conclusions

Listing of NSAIDs on national EMLs should take account of cardiovascular risk, with preference given to low risk drugs. Diclofenac has a risk very similar to rofecoxib, which was withdrawn from worldwide markets owing to cardiovascular toxicity. Diclofenac should be removed from EMLs.
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Old news. Same conclusion from AHA June 2010 review.

http://circoutcomes.ahajournals.org/content/early/2010/06/08/CIRCOUTCOMES.109.861104.short
 
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I think we need a new organization: PRNP for the responsible prescribing of NSAIDs. I propose they only should be used for 3 months maximally, and be restricted to an equivalent of 100mg ibuprofen per day. If we get 40 signatures, we can petition the FDA to change the labeling.... :)
 
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algosdoc said:
I think we need a new organization: PRNP for the responsible prescribing of NSAIDs. I propose they only should be used for 3 months maximally, and be restricted to an equivalent of 100mg ibuprofen per day. If we get 40 signatures, we can petition the FDA to change the labeling.... :)
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using this analogy and perspective, the patient on oxy in the other thread would be using, roughly, 30,000 mg of ibuprofen a day.

(im using the commonly quoted max of 800 mg tid ibuprofen and 120 mg MED that has been quoted)

now 101N and NEPain can take that number and run with it in either direction....
 
algosdoc said:
I think we need a new organization: PRNP for the responsible prescribing of NSAIDs. I propose they only should be used for 3 months maximally, and be restricted to an equivalent of 100mg ibuprofen per day. If we get 40 signatures, we can petition the FDA to change the labeling.... :)
Click to expand...

We should also change NSAIDs to Schedule II medications :D
 
I remember looking up the research while in residency and seeing that if used for over 2 years all NSAIDs increase your stroke risk (except for naproxen 500mg BID, but a lower dose naproxen was more risky)
 
NSAIDS of course cause renal dysfunction used long term, GI bleeds, HTN, CHF, recurrent MI risk increases by 80% after the first MI if continuing to use NSAIDs, etc. They are at least as deadly as opioids to the population as a whole.
 
It's interesting how I've never had a patient threaten to sue me, report me to the state medical board, yell at me and call me uncompassionate and inhumane for discontinuing their diclofenac.
 
algosdoc said:
NSAIDS of course cause renal dysfunction used long term, GI bleeds, HTN, CHF, recurrent MI risk increases by 80% after the first MI if continuing to use NSAIDs, etc. They are at least as deadly as opioids to the population as a whole.
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which is why i rarely prescribe them for longer than 2-3 months. but to contemplate only rarely prescribing opioids for longer than 2-3 months is sacrosanct to medical malpractice for some...
 
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i don't know - i'd rather a patient take aleve BID versus narcotics..

i do get all of my patients off diclofenac oral - and if they insist it is the only thing that works, then i require regular hepatic/renal labs
 
algosdoc said:
NSAIDS of course cause renal dysfunction used long term, GI bleeds, HTN, CHF, recurrent MI risk increases by 80% after the first MI if continuing to use NSAIDs, etc. They are at least as deadly as opioids to the population as a whole.
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False analogy. NSAID use has not increased at the rate that opioids over the past two decades(3-4x). While NSAIDs can be dangerous and responsible for a lot of morbidity/mortality their use is not consider epidemic level. And, NSAIDs, unlike opioids are non-addictive.
 
Opioids do not typically cause 107,000 hospitalizations for gi bleeds, a 1000% increase in heart failure, cause thousands of patients every year to be on dialysis, cause an 80% increae in myocardial infarction, cause a 30% increase in erectile dysfunction, or significant increase in htn. The medical expenditures in this epidemic of death and destruction from nsaidsis counted in billions of dollars every year. So I think it is a very valid comparison....
 
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algosdoc said:
Opioids do not typically cause 107,000 hospitalizations for gi bleeds, a 1000% increase in heart failure, cause thousands of patients every year to be on dialysis, cause an 80% increae in myocardial infarction, cause a 30% increase in erectile dysfunction, or significant increase in htn. The medical expenditures in this epidemic of death and destruction from nsaidsis counted in billions of dollars every year. So I think it is a very valid comparison....
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Again, false analogy. No debate that NSAIDs cause significant morbidity and mortality. Maybe even more than opioids. However, their rate of utilization and associated morbidity/mortality did not increase 4x in the past 20yrs. Not that PHARMA didn't try, they just weren't as successful as with opioids.
 
:troll:

he has an agenda
 
lobelsteve said:
If they made 10mg Norco OTC, there would be no outcry?
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there would be a mad rush to the pharmacies buying up all the available stock...


algos' points are well taken, but it only addresses individual patient concerns with medications.

NSAID are potentially dangerous, but they rarely cause fetal demise from overdose, rarely cause addiction of teenagers or others not prescribed these medications legitimately, and rarely are there crimes committed for attempting to obtain them (ie. break-ins, pharmacy robberies, physicians shot for not prescribing, etc.)
 
The rate of increase in opioid related deaths is actually decreasing according to the latest preliminary data from the cdc. It is still far far too high. The point is that doctors frequently prescribe or recommend otc nsaids in lieu of having viable less toxic alternatives. Everything we prescribe has associated risks and like opioids, the risks of nsaids are numerically similar in mortality and morbidity. We need better alternatives. Perhaps in 5 years we will all be practicing Reiki and giving colonics for pain....
 
algosdoc said:
The rate of increase in opioid related deaths is actually decreasing according to the latest preliminary data from the cdc. It is still far far too high. The point is that doctors frequently prescribe or recommend otc nsaids in lieu of having viable less toxic alternatives. Everything we prescribe has associated risks and like opioids, the risks of nsaids are numerically similar in mortality and morbidity. We need better alternatives.
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Agree.
 
algosdoc said:
Perhaps in 5 years we will all be practicing Reiki and giving colonics for pain....
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Way ahead of you. I'm doing that now. I have to get an edge on my competition, which is doing prolotherapy. This week's special : Cranio-sacral massage. Shift those cranial sutures!
 
algosdoc said:
The rate of increase in opioid related deaths is actually decreasing according to the latest preliminary data from the cdc. It is still far far too high. The point is that doctors frequently prescribe or recommend otc nsaids in lieu of having viable less toxic alternatives. Everything we prescribe has associated risks and like opioids, the risks of nsaids are numerically similar in mortality and morbidity. We need better alternatives. Perhaps in 5 years we will all be practicing Reiki and giving colonics for pain....
Click to expand...

Pharma needs to come up with a molecule that gets mandated to be added to all opioids that gets the opioid to the spinal cord but does not permit it to get to the brain (and all the various nuclei associated with pleasure)...I don't know how that would occur physiologically or anatomically with the blood-brain barrier but a man can dream. Pain relief without addiction. I would be a happy pain physician.
 
painstop said:
Pharma needs to come up with a molecule that gets mandated to be added to all opioids that gets the opioid to the spinal cord but does not permit it to get to the brain (and all the various nuclei associated with pleasure)...I don't know how that would occur physiologically or anatomically with the blood-brain barrier but a man can dream. Pain relief without addiction. I would be a happy pain physician.
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A better pipe dream would be a way to eliminate tolerance to opioids.

Continually escalating doses, just won't work, not that many PCPs wouldn't try to do this anyway.
 
painstop said:
Pharma needs to come up with a molecule that gets mandated to be added to all opioids that gets the opioid to the spinal cord but does not permit it to get to the brain (and all the various nuclei associated with pleasure)...I don't know how that would occur physiologically or anatomically with the blood-brain barrier but a man can dream. Pain relief without addiction. I would be a happy pain physician.
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The answer to sustained pain relief in a chronic pain condition is not the mu receptor. (Maybe someday if it is very specific to a few subtypes on the microglia).
 
lobelsteve said:
All day long. With .5 to 1.8% systemic effect the risk gor liver, kidneys, heart, guy, and brain isnt there.
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Yes, but they dont write that on the label. We logically deduce that. But on the labeling for all these topical NSAIDS the same risks are listed. The same 'disclaimers' are present....
 
PinchandBurn said:
Yes, but they dont write that on the label. We logically deduce that. But on the labeling for all these topical NSAIDS the same risks are listed. The same 'disclaimers' are present....
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not to be too technical, but they actually do write something...

The amount of diclofenac sodium that is systemically absorbed from Voltaren® Gel is on average 6% of the systemic exposure from an oral form of diclofenac sodium.
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taken from the full Prescribing Information pamphlet.
 
I stand corrected.

It looks like it can range from less than 1% to 3.3% for Pennsaid and 6% for Volt gel.

Diclofenac systemic exposure from PENNSAID application (4 times daily for 1 week) was calculated to be 3.3%.27*
Systemic exposure of PENNSAID is estimated to be 1/125 of oral diclofenac (100 mg daily)24

And AMP- those are class effects, not particularly the drug being prescribed.
 
lobelsteve said:
And AMP- those are class effects, not particularly the drug being prescribed.
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Steve - the reason the black box warning is on the topicals is that no studies have been done to demonstrate that the GI or CV risks are decreased. We presume they will be, based on decreased systemic uptake, but until it has been documented, all that us is an assumption.
 
ampaphb said:
Steve - the reason the black box warning is on the topicals is that no studies have been done to demonstrate that the GI or CV risks are decreased. We presume they will be, based on decreased systemic uptake, but until it has been documented, all that us is an assumption.
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Until the studies are done I'll assume aspercreme is fine for MI and stroke prophylaxis.
 
ampaphb said:
Steve - the reason the black box warning is on the topicals is that no studies have been done to demonstrate that the GI or CV risks are decreased. We presume they will be, based on decreased systemic uptake, but until it has been documented, all that us is an assumption.
Click to expand...

The FDA has issued so many black box warnings now, I'm surprised anyone even quotes them or pays attention to them anymore.
 
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