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Topical NSAIDs Offer Rub-on Relief

Topical diclofenac (like Voltaren gel) may relieve pain with less risk of side effects. Is it right for you?

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If you have arthritis in just a couple joints, you may not need to expose yourself to the risks of oral nonsteroidal anti-inflammatory drugs (NSAIDs) – such stomach upset or heart problems – to achieve some relief. A topical NSAID can be rubbed on the skin over sore joints to relieve pain.

What Are Topical NSAIDs?

First approved in the United States in 2007, topical diclofenac formulations are now available as gels, liquids and patches. Different strengths are available for different purposes. All require a prescription.

Authors of a 2016 review published in Seminars in Arthritis & Rheumatism conclude, “Topical NSAIDs have a moderate effect on pain relief, with efficacy similar to that of oral NSAIDs, with the advantage of a better risk:benefit ratio.” However, A 2016 Cochrane review looked at 39 studies with 10,631 participants and found that topical diclofenac, “can provide good levels of pain relief in osteoarthritis, but only for about 10% more people than get this result with topical placebo.”

So topical NSAIDs aren’t for everyone, but for people who can’t  or don’t want to take oral NSAIDs, they can be a good option.

What Is Available?

  • Diclofenac sodium 1% gel (Voltaren, also available as a generic). When used for osteoarthritis pain of the hands, elbows or wrists, apply 2 grams to each affected area four times a day (a total of 8 grams per day). When used on knees, ankles, or feet, apply 4 grams to each affected area four times a day (a total of 16 grams per day).  However, the total amount used on your body should not exceed 32 grams per day. A dosing card comes with the gel so you can measure the correct amount.
  • Diclofenac epolamine 1.3% patch (Flector). Apply one patch to your most painful joint twice per day.
  • Diclofenac sodium 1.5% liquid (Pennsaid). When used for osteoarthritis knee pain, apply 40 drops per knee, 4 times a day. Dispense in 10-drop portions to prevent spilling.
  • Diclofenac sodium 2% liquid (Pennsaid). When used for osteoarthritis knee pain, apply 40 mg (2 pumps) on each painful knee, 2 times a day.
  • Diclofenac sodium 3% gel (Solaraze). This strength gel is approved for use in treating actinic keratosis, a skin condition. It has not been approved for use in arthritis.
  • Specialized Options. Other NSAIDs, such as ibuprofen, ketoprofen, indomethacin and piroxicam can be made into topical solutions at a compounding pharmacy. This could raise the price and insurance may not reimburse you for the medicine.

 Are Topical NSAIDs Right for Me?

These gels, liquids or patches may work for you if:

  • You have arthritis in smaller joints. Topical NSAIDs will penetrate the skin and help reduce pain locally. They work best on joints that are closer to the surface, such as the hands, knees, elbows and ankles.
  • You are older than 65. “A lot of elderly patients can’t take oral NSAIDs because they have stomach or heart risk factors, and they can’t take narcotic analgesics because they could become so drowsy they could fall and break a bone,” says Roy D. Altman, MD, professor of medicine in the division of rheumatology and immunology at the University of California, Los Angeles.
  • Your stomach is sensitive to NSAIDs. Using topical NSAIDs may help you avoid a tummy ache. But if you have a history of ulcers or gastrointestinal bleeding, the medicine in the drug travels through your blood and can still put you at risk.
  • You have heart risk factors. The gel’s active ingredients still make it into your bloodstream and can still affect your cardiovascular system. But the amount absorbed is much less, reducing your heart risk compared with oral NSAIDs.

The topical NSAIDs may not be right for you if:

  • You also take oral NSAIDs. Topical diclofenac should not be used in combination with oral NSAIDs or aspirin because of the potential for adverse effects. The gel’s active ingredient still gets into your bloodstream, so you have to consider the total amount you’re getting from every route, Dr. Altman says.
  • You have sensitive skin. Some people may have skin reactions where the medicine is applied.
  • You have several affected joints. “Voltaren works fairly quickly – within a week – but the pill works quicker,” says Dr. Altman. And taking a pill would be a lot easier for someone who has multiple joints affected by arthritis, he says. You also have to make sure you don’t exceed the total recommended dosage by slathering it on multiple joints.
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