Non-steroidal anti-inflammatory drugs (NSAIDs)
Brand names: Voltaren
Updated · Methodology
First line
Diclofenac 50 mg 2–3 times daily or 75 mg twice daily is one of the most effective NSAIDs for pain of various origins. Maximum daily dose 150 mg. Surpasses ibuprofen in analgesic potency. Short course of 5–7 days is preferred. If prolonged use is needed, cardiovascular and gastrointestinal risk must be assessed.
Sources
ICD-10: R52 · ICD-11: MG31
First line
For osteoarthritis, OA 2022 recommends starting with topical NSAIDs – diclofenac gel applied to the affected joint 3–4 times daily. Topical form provides local effect with minimal systemic exposure. Oral diclofenac is used when topical therapy is insufficient. Due to high cardiovascular risk, short courses are preferred.
Sources
ICD-10: M19 · ICD-11: FA0Z
First line
Diclofenac is first-line for renal colic. Administered intramuscularly 75 mg or rectally 100 mg. Efficacy is comparable to opioid analgesics with less nausea and vomiting. A 2015 Cochrane review confirmed NSAIDs' advantage over antispasmodics in renal colic.
Sources
ICD-10: N23 · ICD-11: MF56
Second line
Symptomatic relief of pain and inflammation in rheumatoid arthritis. It does not affect disease progression; patients take it on top of disease-modifying therapy (methotrexate and other DMARDs), which controls RA. Per , , and the Spanish GUIPCAR, use it minimally and briefly: diclofenac carries the highest cardiovascular risk among NSAIDs, plus gastrointestinal risk.
Sources
ICD-10: M06.9 · ICD-11: FA20.Z
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID). It is prescribed for osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and acute pain (AEMPS Ficha Técnica). In anti-aging circles, diclofenac is promoted as an anti-aging drug to suppress low-grade inflammation in healthy adults, citing older work on inflammation and aging. Regular diclofenac use in people without a confirmed inflammatory disease is not justified: the Bhala 2013 meta-analysis (CNT collaboration, over 350,000 patients) showed that diclofenac increases cardiovascular events by 40% versus placebo, more than most other NSAIDs. Regular use also elevates the risk of gastrointestinal bleeding and acute kidney injury. If diclofenac was prescribed for chronic use against aging-related inflammation, consider seeking a second opinion.
Non-selective cyclooxygenase inhibitor with greater COX-2 selectivity than ibuprofen. Potent anti-inflammatory effect through prostaglandin synthesis suppression and inhibition of leukocyte migration to the site of inflammation. Analgesic onset within 20–30 minutes of oral intake. Available as oral, rectal, intramuscular, and topical formulations.
AEMPS summary of product characteristics (section 4.6): in the first and second trimesters, diclofenac is used only if strictly necessary, and in women trying to conceive and in these trimesters the dose and duration are kept as low as possible; it is contraindicated in the third trimester. Epidemiological studies suggest an increased risk of miscarriage, cardiac malformations and gastroschisis after early use of prostaglandin synthesis inhibitors (the absolute risk of cardiac malformations rose from about 1% to about 1.5%), although data on miscarriage are inconclusive; the risk appears to increase with dose and duration. From week 20, diclofenac can cause oligohydramnios due to fetal renal dysfunction, and constriction of the ductus arteriosus has been reported after second-trimester treatment; both usually resolve after stopping. After exposure for several days from week 20, prenatal monitoring for oligohydramnios and ductus constriction should be considered, and treatment is stopped if either is found. In the third trimester, prostaglandin synthesis inhibitors expose the fetus to cardiopulmonary toxicity (constriction or premature closure of the ductus arteriosus, pulmonary hypertension) and to renal dysfunction that may progress to renal failure with oligohydramnios; at the end of pregnancy, mother and newborn may have a prolonged bleeding time, and inhibited uterine contractions can delay or prolong labour.
Excreted in breast milk in small amounts. Short-term use is acceptable. If prolonged treatment is needed, ibuprofen is preferred.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
17 pairs found. Sorted from critical to minor.
Mechanism
Ketorolac and diclofenac are both NSAIDs. Co-administration adds up the risks: gastrointestinal bleeding, acute kidney injury, raised blood pressure. Toradol Section 4.3 specifically lists other NSAIDs as contraindications.
Symptoms
Black or tarry stools (melena), vomiting blood or coffee-ground material, epigastric pain. Acute kidney injury and a rise in blood pressure are also possible. Risk of bleeding multiplies in patients over 65 and with prior peptic ulcer disease.
Management
The combination is not prescribed. For adequate analgesia, choose one NSAID as monotherapy (diclofenac or ketorolac short course with PPI cover such as pantoprazole). Alternative: paracetamol plus an opioid if pain is insufficiently controlled.
Sources
Mechanism
Diclofenac competitively inhibits platelet cyclooxygenase-1 and blocks aspirin's access for COX-1 acetylation. Co-administration loses aspirin's cardioprotective effect. Additive ulcerogenic effect of two NSAIDs.
Symptoms
Black or tarry stools (melena), vomiting blood or coffee-ground material, epigastric pain. Risk multiplies in older patients and with prior peptic ulcer disease.
Management
If the patient takes aspirin for cardioprotection, give aspirin 30 minutes before or 8 hours after diclofenac. Alternative analgesic without this issue: paracetamol or a selective COX-2 inhibitor (celecoxib).
Sources
Mechanism
Apixaban inhibits factor Xa; diclofenac injures the gastric mucosa and reduces platelet aggregation. Diclofenac additionally raises cardiovascular event risk, which matters in atrial fibrillation patients.
Symptoms
Gum bleeding, epistaxis, bruising without trauma, blood in urine or stool, menorrhagia. Severe cases include gastrointestinal or intracranial haemorrhage. Risk rises in patients over 65 and with prior peptic ulcer disease.
Management
Avoid where possible. If diclofenac is needed for a short course, use the minimum effective dose for no more than 5–7 days under pantoprazole cover. For chronic analgesia, choose paracetamol, celecoxib, or topical NSAIDs.
Sources
Symptoms
Reduced urine output, rising creatinine and potassium, oedema. Symptoms appear earlier in older patients and in chronic kidney disease.
Management
Avoid prolonged combination. If diclofenac is needed for a short course, use the minimum effective dose for 5–7 days with creatinine monitoring. For chronic analgesia: paracetamol or celecoxib.
Sources
Mechanism
Both labels point to the same spot from opposite sides. The dexamethasone label states that non-steroidal anti-inflammatories, for example indometacin and salicylates, increase the risk of ulcer and gastrointestinal bleeding. The diclofenac label notes that concomitant use with other NSAIDs or corticosteroids can increase gastrointestinal adverse effects. The steroid also retains sodium and raises blood glucose, adding to the renal and blood pressure effect of the NSAID.
Symptoms
Epigastric pain, nausea, black stools, coffee-ground vomit. The steroid masks fever and pain, so a perforation may present with few symptoms. Add high blood glucose in diabetics, oedema and rising blood pressure.
Management
Avoid overlapping the two unless clearly indicated, and then for the shortest time. When the combination is necessary, add gastric protection with a proton pump inhibitor and monitor stools, haemoglobin and blood glucose. For background pain, paracetamol allows the NSAID to be reduced or dropped.
Sources
Mechanism
The diclofenac label notes that giving it with other NSAIDs or corticosteroids can increase gastrointestinal adverse effects, and the ibuprofen label asks to avoid simultaneous use with other NSAIDs. On top of the digestive risk comes the cardiovascular one, highest in the group for diclofenac at high doses and long courses.
Symptoms
Epigastric pain, dyspepsia, black stools, anaemia from slow bleeding. Fluid retention, rising blood pressure and worse hypertension control. In ischaemic heart disease the thrombotic risk of diclofenac outweighs any analgesic gain.
Management
Keep a single NSAID, and in cardiovascular patients avoid choosing diclofenac. Topical diclofenac gels and patches contribute little systemically, but over large areas or under occlusive dressing absorption rises and they count as another dose. Extra analgesia comes from paracetamol.
Sources
Mechanism
Similar to naproxen + lithium. NSAIDs reduce renal lithium clearance via prostaglandin blockade.
Symptoms
Tremor, muscle twitching, nausea, diarrhoea, confusion, ataxia. Symptoms emerge when serum lithium exceeds 1.2 mmol/L.
Management
Avoid prolonged combination. If diclofenac is needed for a short course, reduce lithium by 25–30% and check level at 5–7 days. For chronic analgesia: paracetamol.
Sources
Mechanism
Diclofenac, like other NSAIDs, reduces methotrexate renal clearance. With high-dose methotrexate – fatal myelosuppression and nephrotoxicity. With low-dose methotrexate – higher risk of cytopenia and liver injury.
Symptoms
Same as with ibuprofen: mucositis, cytopenia, rising creatinine and transaminases.
Management
Same approach as methotrexate+ibuprofen. If a rheumatoid arthritis patient needs an NSAID, prefer paracetamol or a short ibuprofen course with lab monitoring.
Sources
Mechanism
Similar to ibuprofen – additive GI bleeding risk. Diclofenac has a higher ulcerogenic potential among NSAIDs.
Symptoms
Black or tarry stools (melena), vomiting blood or coffee-ground material, epigastric pain. Risk multiplies in older patients and with prior peptic ulcer disease.
Management
Avoid prolonged combination. If diclofenac is needed, use the minimum effective dose for 5–7 days with mandatory pantoprazole cover. For chronic analgesia: paracetamol or celecoxib.
Sources
Mechanism
Additive GI bleeding risk: anticoagulant (rivaroxaban) + ulcerogenic NSAID (diclofenac). Diclofenac additionally raises cardiovascular risk.
Symptoms
Black or tarry stools (melena), vomiting blood or coffee-ground material, epigastric pain. Risk multiplies in older patients and with prior peptic ulcer disease.
Management
Avoid prolonged combination. If diclofenac is needed for a short course, use the minimum effective dose for 5–7 days under pantoprazole cover. For chronic analgesia: paracetamol, celecoxib (less GI toxicity), or topical NSAIDs.
Sources
Mechanism
Diclofenac (NSAID) suppresses renal prostaglandin synthesis maintaining glomerular perfusion. Tacrolimus is nephrotoxic in its own right. Additive acute kidney injury risk in transplant patients.
Symptoms
Reduced urine output, rising creatinine, potassium accumulation. In kidney transplant patients: accelerated graft function decline.
Management
Avoid chronic diclofenac on tacrolimus. For analgesia post-transplant, use paracetamol (up to 2 g/day) or a short opioid course. For neuropathic pain, gabapentin or pregabalin.
Sources
Mechanism
Diclofenac (NSAID) inhibits platelet aggregation, injures the gastric mucosa, and weakly displaces warfarin from albumin binding. Additive GI bleeding risk independent of INR.
Symptoms
Gum bleeding, epistaxis, bruising without trauma, blood in urine or stool, menorrhagia. Severe cases include gastrointestinal or intracranial haemorrhage. Risk rises in patients over 65 and with prior peptic ulcer disease.
Management
Avoid chronic diclofenac on warfarin. For analgesia, choose paracetamol (up to 2 g/day for short courses). For chronic NSAID needs, use a selective COX-2 inhibitor (celecoxib) under pantoprazole cover.
Sources
Mechanism
No direct pharmacokinetic interaction. Additive bleeding risk in patients on concurrent warfarin or amiodarone (the latter enhances anticoagulation via CYP2C9 inhibition).
Symptoms
Epigastric pain, heartburn, black or tarry stools, gum bleeding, bruising. Higher risk in older patients and prior peptic ulcer disease.
Management
For short diclofenac courses (3–7 days), no specific adjustment needed. For long-term needs, consider paracetamol up to 2 g/day, topical NSAIDs, or physiotherapy. Avoid NSAIDs on a warfarin-amiodarone regimen.
Sources
Mechanism
NSAIDs weaken amlodipine's antihypertensive effect via prostaglandin suppression. Diclofenac additionally raises cardiovascular risk.
Symptoms
Gradual blood pressure rise 1–2 weeks after starting the NSAID. In chronic kidney disease: risk of fluid retention and oedema.
Management
Avoid prolonged diclofenac use. For acute pain: short course (5–7 days) with pantoprazole cover. For chronic analgesia: paracetamol, celecoxib, or topical NSAIDs.
Sources
Mechanism
NSAIDs weaken the antihypertensive effect of beta-blockers via renal prostaglandin suppression. Diclofenac is one of the most ulcerogenic NSAIDs with elevated cardiovascular risk.
Symptoms
Gradual blood pressure rise 1–2 weeks after starting the NSAID. In chronic kidney disease: risk of fluid retention and oedema.
Management
Avoid prolonged diclofenac use. For acute pain: short course (5–7 days) with pantoprazole cover. For chronic analgesia: paracetamol, celecoxib, or topical NSAIDs.
Sources
Mechanism
Glucocorticoid plus NSAID — additive GI ulcer and bleeding risk with systemic budesonide. Inhaled budesonide does not clinically affect risk.
Symptoms
Epigastric pain, heartburn, black or tarry stools, blood in vomit, bruising. Higher risk in older patients, prior peptic ulcer, and concurrent anticoagulants.
Management
On systemic budesonide, limit diclofenac to short courses (no more than 5–7 days) with pantoprazole 20 mg/day. For long-term analgesia: paracetamol up to 2 g/day or topical NSAIDs. Inhaled budesonide with diclofenac is safe. In older patients and prior peptic ulcer, risk outweighs benefit.
Mechanism
Additive nephrotoxicity. NSAIDs reduce renal blood flow by suppressing vasodilatory prostaglandin synthesis; contrast adds tubular osmotic load. Contrast-induced AKI risk rises 2–3-fold.
Symptoms
Decreased urine output, rising creatinine, oedema, nausea. Symptoms develop 24–72 hours after contrast.
Management
Stop diclofenac 24–48 hours before elective contrast imaging; restart 48 hours after the study once creatinine normalises. With creatinine clearance below 60 mL/min, give IV isotonic hydration 6–12 hours before and 6–12 hours after imaging. Analgesic alternative: paracetamol up to 3 g/day.
Sources
Verbatim lines from the interaction sections, in the language of the label
«Riesgos gastrointestinales: Al igual que los demás AINEs, diclofenaco, se ha de tener precaución cuando se prescriba diclofenaco en pacientes con síntomas indicativos de alteraciones…»AEMPS, section 4.4 · Open on CIMA
«Fármacos que pueden causar una hiperpotasemia : El tratamiento concomitante con fármacos ahorradores de potasio, ciclosporina, tacrolimus o trimetoprim puede asociarse con un aumento de los niveles…»AEMPS, section 4.5 · Open on CIMA
«Antagonistas del calcio (Isradipino, verapamilo): Hay estudios en los que se ha registrado una disminución en su eficacia terapéutica por acción de diclofenaco.»AEMPS, section 4.5 · Open on CIMA
«Anticoagulantes y antiagregantes plaquetarios: Se recomienda precaución dado que la administración concomitante podría aumentar el riesgo de hemorragia (ver sección 4.4). Pese a que las…»AEMPS, section 4.5 · Open on CIMA
«Anticoagulantes y antiagregantes plaquetarios: Se recomienda precaución dado que la administración concomitante podría aumentar el riesgo de hemorragia (ver sección 4.4). Pese a que las…»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Intervention: Monitor patients with concomitant use of diclofenac sodium gel with anticoagulants (e.g., warfarin), antiplatelet agents (e.g., aspirin), selective serotonin reuptake…»FDA, section 7 · Open on DailyMed
«Antidiabéticos: Los ensayos clínicos han demostrado que diclofenaco puede administrarse junto con antidiabéticos orales sin que influya sobre su efecto clínico. Sin embargo, se han notificado casos…»AEMPS, section 4.5 · Open on CIMA
«Antidiabéticos: Los ensayos clínicos han demostrado que diclofenaco puede administrarse junto con antidiabéticos orales sin que influya sobre su efecto clínico. Sin embargo, se han notificado casos…»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Intervention: Monitor patients with concomitant use of diclofenac sodium gel with anticoagulants (e.g., warfarin), antiplatelet agents (e.g., aspirin), selective serotonin reuptake…»FDA, section 7 · Open on DailyMed
«DRUG INTERACTIONS: Intervention: During concomitant use of diclofenac sodium gel and ACE-inhibitors, ARBs, or beta-blockers, monitor blood pressure to ensure that the desired blood pressure is…»FDA, section 7 · Open on DailyMed
«DRUG INTERACTIONS: Intervention: During concomitant use of diclofenac sodium gel and ACE-inhibitors, ARBs, or beta-blockers, monitor blood pressure to ensure that the desired blood pressure is…»FDA, section 7 · Open on DailyMed
«Fármacos antihipertensivos: Como otros AINEs, el uso concomitante de diclofenaco y diuréticos o fármacos antihipertensivos (p.ej. beta-bloqueantes, inhibidores de la enzima convertidora de la…»AEMPS, section 4.5 · Open on CIMA
«Riesgos gastrointestinales: Se debe recomendar una precaución especial a aquellos pacientes que reciben tratamientos concomitantes que podrían elevar el riesgo de úlcera o sangrado gastrointestinal…»AEMPS, section 4.4 · Open on CIMA
«Digoxina : Si se usa concomitantemente, diclofenaco puede aumentar las concentraciones plasmáticas de digoxina. Se recomienda el control de los niveles séricos de digoxina.»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Intervention: During concomitant use of diclofenac sodium gel and digoxin, monitor serum digoxin levels.»FDA, section 7 · Open on DailyMed
«Fármacos antihipertensivos: Como otros AINEs, el uso concomitante de diclofenaco y diuréticos o fármacos antihipertensivos (p.ej. beta-bloqueantes, inhibidores de la enzima convertidora de la…»AEMPS, section 4.5 · Open on CIMA
«Fármacos que pueden causar una hiperpotasemia : El tratamiento concomitante con fármacos ahorradores de potasio, ciclosporina, tacrolimus o trimetoprim puede asociarse con un aumento de los niveles…»AEMPS, section 4.5 · Open on CIMA
«Fármacos antihipertensivos: Como otros AINEs, el uso concomitante de diclofenaco y diuréticos o fármacos antihipertensivos (p.ej. beta-bloqueantes, inhibidores de la enzima convertidora de la…»AEMPS, section 4.5 · Open on CIMA
«Antibacterianos : Inhibidores de CYP2C9 : se recomienda precaución cuando se prescribe diclofenaco con inhibidores de CYP2C9 (voriconazol), que incrementan significativamente las concentraciones…»AEMPS, section 4.5 · Open on CIMA
«Riesgos gastrointestinales: Se debe recomendar una precaución especial a aquellos pacientes que reciben tratamientos concomitantes que podrían elevar el riesgo de úlcera o sangrado gastrointestinal…»AEMPS, section 4.4 · Open on CIMA
«Litio: Si se usa concomitantemente, diclofenaco puede aumentar la concentración plasmática de litio. Se recomienda el control de los niveles séricos de litio.»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Intervention: During concomitant use of diclofenac sodium gel and lithium, monitor patients for signs of lithium toxicity.»FDA, section 7 · Open on DailyMed
«Metotrexato : Diclofenaco inhibe el aclaramiento renal tubular de metrotrexato por tanto aumenta los niveles de metrotrexato. Se recomienda precaución cuando se administren agentes no esteroideos…»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Intervention: During concomitant use of diclofenac sodium gel and methotrexate, monitor patients for methotrexate toxicity.»FDA, section 7 · Open on DailyMed
«Antibacterianos : Fenitoina : cuando se utiliza concomitantemente fenitoína con diclofenaco, se recomienda una monitorización de los niveles plasmáticos de la fenitoína, ya que se espera un aumento a…»AEMPS, section 4.5 · Open on CIMA
«Antibacterianos : Inductores de CYP2C9: se recomienda precaución cuando se prescribe diclofenaco con inductores de CYP2C9 (como rifampicina), que pueden dar lugar a un descenso significativo de la…»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Intervention: Monitor patients with concomitant use of diclofenac sodium gel with anticoagulants (e.g., warfarin), antiplatelet agents (e.g., aspirin), selective serotonin reuptake…»FDA, section 7 · Open on DailyMed
«Fármacos que pueden causar una hiperpotasemia : El tratamiento concomitante con fármacos ahorradores de potasio, ciclosporina, tacrolimus o trimetoprim puede asociarse con un aumento de los niveles…»AEMPS, section 4.5 · Open on CIMA
«Fármacos que pueden causar una hiperpotasemia : El tratamiento concomitante con fármacos ahorradores de potasio, ciclosporina, tacrolimus o trimetoprim puede asociarse con un aumento de los niveles…»AEMPS, section 4.5 · Open on CIMA
«Antagonistas del calcio (Isradipino, verapamilo): Hay estudios en los que se ha registrado una disminución en su eficacia terapéutica por acción de diclofenaco.»AEMPS, section 4.5 · Open on CIMA
«Antibacterianos : Inhibidores de CYP2C9 : se recomienda precaución cuando se prescribe diclofenaco con inhibidores de CYP2C9 (voriconazol), que incrementan significativamente las concentraciones…»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Intervention: Monitor patients with concomitant use of diclofenac sodium gel with anticoagulants (e.g., warfarin), antiplatelet agents (e.g., aspirin), selective serotonin reuptake…»FDA, section 7 · Open on DailyMed
«DRUG INTERACTIONS: ACE Inhibitors, Angiotensin Receptor Blockers, and Beta-Blockers»FDA, section 7 · Open on DailyMed
«Antibacterianos : Ceftriaxona: Hay estudios en los que se ha registrado un incremento de su eliminación por el diclofenaco.»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: Clinical Impact: NSAIDs may diminish the antihypertensive effect of angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or beta-blockers…»FDA, section 7 · Open on DailyMed
«Debido a que la vinpocetina disminuye la agregación plaquetaria, debe evitarse en pacientes en tratamiento con medicamentos antiagregantes o anticoagulantes. Por lo tanto, debe evitarse la…»AEMPS, section 4.5 · Open on CIMA
«Combinaciones con mayor riesgo de nefrotoxicidad: Deberá tenerse precaución cuando se utilice ciclosporina junto con otros fármacos que presentan sinergia nefrotóxica como son: aminoglucósidos…»AEMPS, section 4.5 · Open on CIMA
«Pharmacokinetic Drug Interactions: Alprazolam, azithromycin, cyclosporine, diclofenac, diphenoxylate, epoprostenol, esomeprazole, ibuprofen, ketoconazole, lansoprazole, metformin, omeprazole Measure…»FDA, section 7 · Open on DailyMed
«Aunque no se ha estudiado específicamente, fluconazol tiene el potencial de aumentar la exposición sistémica de otros AINEs que se metabolizan por el CYP2C9 (p. ej. naproxeno, lornoxicam, meloxicam…»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: NSAIDs Non-Steroidal Anti-Inflammatory Drug including: ibuprofen and diclofenac (CYP2C9 Inhibition) Increased Frequent monitoring for adverse reactions and toxicity related to…»FDA, section 7 · Open on DailyMed
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Diclofenac is evaluated for the following indications with varying evidence strength: Renal colic (evidence tier A), Mild to moderate pain in adults (evidence tier A), Osteoarthritis (evidence tier A). See the full indication matrix with dosing and citations above on this page.
Common side effects of Diclofenac (≥ 1 in 100): Dyspepsia, epigastric pain, nausea, Headache, dizziness, Elevated liver transaminases, Fluid retention, edema. See the Safety section for uncommon and serious reactions.
AEMPS summary of product characteristics (section 4.6): in the first and second trimesters, diclofenac is used only if strictly necessary, and in women trying to conceive and in these trimesters the dose and duration are kept as low as possible; it is contraindicated in the third trimester. Epidemiological studies suggest an increased risk of miscarriage, cardiac malformations and gastroschisis after early use of prostaglandin synthesis inhibitors (the absolute risk of cardiac malformations rose from about 1% to about 1.5%), although data on miscarriage are inconclusive; the risk appears to increase with dose and duration. From week 20, diclofenac can cause oligohydramnios due to fetal renal dysfunction, and constriction of the ductus arteriosus has been reported after second-trimester treatment; both usually resolve after stopping. After exposure for several days from week 20, prenatal monitoring for oligohydramnios and ductus constriction should be considered, and treatment is stopped if either is found. In the third trimester, prostaglandin synthesis inhibitors expose the fetus to cardiopulmonary toxicity (constriction or premature closure of the ductus arteriosus, pulmonary hypertension) and to renal dysfunction that may progress to renal failure with oligohydramnios; at the end of pregnancy, mother and newborn may have a prolonged bleeding time, and inhibited uterine contractions can delay or prolong labour.
Excreted in breast milk in small amounts. Short-term use is acceptable. If prolonged treatment is needed, ibuprofen is preferred.
Diclofenac is contraindicated in: Established coronary artery disease, prior MI or stroke; Heart failure (NYHA II-IV); Uncontrolled arterial hypertension; Active peptic ulcer disease or GI bleeding; Severe renal impairment (eGFR below 30). Full list in the Safety section.
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Etoricoxib, Glucosamine, Glucosamine + Chondroitin, Ibuprofen, Ketorolac, Stinging nettle leaf, Aceclofenac, Ketoprofen