Q&A: Why can I no longer use diclofenac?

Questions:

I am 71 years old and have been taking diclofenac for years to control pains from arthritis in my feet. I have been told that I can no longer be prescribed it due to a slight risk of a heart attack. I have had side effects from all the other drugs that I have been prescribed ie gabapantin, indometacin and currently amitriptyline. These latest ones are making me sleep well and feel groggy the next day but with no pain relief. I had no side effects at all with diclofenac. Why can I no longer have it? Is it due to cost?

-Linda

Answer:

Dr Sarah Jarvis says: “I’m sorry you’re struggling with pain from arthritis. However, I’m afraid there are very good reasons for your doctor recommending that you stop diclofenac and they are nothing to do with cost. Diclofenac has been around for decades and is extremely cheap, but over the last few years more and more evidence has been emerging about an increased risk of heart attack and stroke associated with taking diclofenac. More recently, there has also been a suggestion that in high doses, there may also be risks from other ‘NSAIDs’, or non-steroidal anti inflammatory drugs, including ibuprofen. Ibuprofen is very commonly prescribed and available without prescription in many countries, but in September 2015 the FDA (Food and Drug Administration) in the USA started insisting on stiffer warnings for all NSAIDs, which should state:

  • The risk of heart attack can occur within weeks of starting an NSAID, and that risk may increase with longer use
  • The risk seems to be higher at higher doses
  • It’s not clear if the risk of heart attack and stroke is the same for all NSAIDs
  • The drugs can raise the risk of heart attack or stroke, both in patients with a risk of heart disease and patients without
  • Patients with heart disease or risk factors for it are at a greater risk of heart attack or stroke following the use of NSAIDs, because they have a higher risk at baseline
  • There is also an increased risk of heart failure for patients using NSAIDs.

It’s important for people who take the occasional NSAID not to panic, but it has definitely made doctors across the world rethink their strategy for treating patients with long-term pain from conditions like arthritis. However, NSAIDs can also cause indigestion (and sometimes bleeding from the stomach), and occasionally cause severe damage to the kidneys, especially in older people. I certainly wouldn’t be recommending that you take indometacin, which is also an NSAID. If I do prescribe NSAIDs, I usually give naproxen, which as yet has not shown the same level of heart attack risk. However, even here I prescribe the lowest dose I can for the shortest time possible.”

-Dr Sarah Jarvis