The widespread use of diclofenac in the UK indicates an immediate need for reconsideration of its use ahead of low-dose ibuprofen or naproxen (with a PPI if appropriate), in people at risk of CV disease who require an NSAID.
Current advice from the CHM is that patients should not switch between NSAIDs without careful consideration of the overall safety profile of the products and the patients’ individual risk factors and preferences.
Although the risks to an individual may be low, when used in the population the NSAID-related GI and CV effects constitute significant risks to public health, and at the next routine review the choice of NSAID should be reviewed.
The ideal anti-inflammatory prescribing choice will vary from patient to patient, depending on individual risk factors, therapeutic response and individual tolerability of increased GI and CV risks with medication. Patients should use the lowest effective dose, and the shortest duration of therapy necessary to control symptoms.
When reviewing the treatment of patients already receiving diclofenac, some patients, after discussion, may decide to continue treatment with diclofenac. However, in some cases (especially patients with risk factors for CV disease) it may be appropriate to consider alternatives:
Patients who change from diclofenac 150mg/day to ibuprofen 1200mg/day would probably reduce both their GI and CV thrombotic risk, especially if the opportunity is taken to introduce a PPI. High doses of ibuprofen (e.g. 2400mg/day) are not prescribed frequently in clinical practice, and the relative risks versus diclofenac are unclear.
Patients who change from diclofenac 150mg/day to naproxen 1000mg/day would reduce their CV thrombotic risk, but may slightly increase their risk of GI complications. However, if the opportunity is taken to introduce a PPI, the GI risks may also be reduced. There is less evidence for the balance of risks with lower doses of diclofenac and naproxen.
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