Topical application of prescription medications has increased in popularity and indication (pain, hypertension, estrogen replacement, cardiac), with the introduction many decades ago of nitroglycerin paste (ointment) for cardiac angina (heart pain due to decreased oxygen to the heart muscle). Benefits of topical include reduced stomach problems in bypassing digestion and breakdown of the drug; compliance-patients applying a patch can see it, thus reducing the problem of remembering whether or not a dose was taken, and the usual 8-12-24 hour duration of patient dosing, reduces problems of subordinate blood therapeutic levels.
Many generations of “transdermal delivery systems’ (patches, dots, etc) have been introduced to improve steady state(constant controllable) delivery of the medication into the blood stream and thus the body’s receptor sites for therapeutic benefit. They are usually of a 3 layer system, the epidermal (skin layer) the drug layer and the outer layer. Allergic skin reactions, proper adherence, and bioavailability (blood concentration levels of the drug) are among the reasons for revision and redevelopment. Gels, such as Voltaren(diclofenac sodium 1%) have the advantage of simply opening a tube(non-child resistant nor difficult for the arthritic patient) and squeezing out a prescribed amount based upon size, “an inch every 8 hours” etc. The medication comes with a measuring guide, but size in inches makes compliance of dosing fairly easy.
Voltaren Gel 1%( manufactured by Endo pharmaceuticals), is indicated for relief of joint pain due to osteoarthritis (degenerative joint disease, DJD), such as the knees, hands, foot, ankle (the “superficial “joints) as opposed to “deeper’ joints such as the hip or spine. As all medication, doses have been established and should be used as prescribed. Many times patients overuse topical medication whether OTC or Rx not understanding it DOES GET INTO THE BLOOD STREAM TO BE EFFECTIVE, JUST AS AN ORAL MEDICATION. Total daily doses should not exceed 32 grams, being measured with the enclosed guide in 2 gram (each elbow, wrist, or hand) or 4 gram increments (each ankle, foot, or knee). For joints of the lower extremity-maximum daily doses should not exceed 16 grams PER JOINT versus upper extremity of 8 grams per day PER JOINT.
Voltaren, an NSAID non-specific prostaglandin inhibitor, should be avoided in patients with allergic reactions, precipitated asthma or skin reactions to aspirin or other NSAIDs, or patients who have had coronary artery bypass(CABG). Aspirin and Voltaren Gel main increase the risk of stomach problems or symptoms. Prolonged use (studies of up to 3 years) may increase the risk of cardiovascular thrombotic events (clots), heart attacks (MI), and stroke (CVA). Prolonged use of the agent by itself may also induce stomach ulcers, bleeding, small or large intestine bleeding. Liver enzyme changes are less likely with topical Voltaren than oral diclofenac, but routine blood tests should be performed for patients with prolonged usage and discontinued if elevated.
Voltaren gel may lead to hypertension (high blood pressure) or worsen previously diagnosed patients. The efficiency of certain diuretics-loop or thiazides may be reduced in patients on NSAIDs. Patients with CHF (congestive heart failure) may experience increased fluid retention. Long term uses of NSAIDs may result in kidney disease especially those patients with reduced kidney function, heart failure, or liver dysfunction, and taking ACE blood pressure medications and the elderly. Regular blood tests should be conducted, with usual return to normal upon discontinuing medicine.
Voltaren should not be applied to open skin, and if a rash develops, the medication should be stopped. Serious skin reactions may occur and any signs of excessive peeling should be directed to the physician immediately. Pregnant women, especially last trimester, should avoid using Voltaren. Patients should avoid excessive skin exposure as it may stimulate UV induced skin tumors.
Drug interactions with topical diclofenac may occur with, aspirin, anticoagulants, ACE inhibitors, diuretics, lithium, methotrexate, oral NSAIDs and should be used with caution. Other topical treatments such as sunscreens, cosmetics, lotions, moisturizers should be avoided as they may alter the absorption of Voltaren.
Voltaren gel is applied, in proper dose, to the applicator card, and then rubbed into to affected area. The card should be properly disposed of thereafter and washing should be avoided for at least 1 hours.
Voltaren Gel Highlights of Prescribing Information for the Physician, Novartis Consumer Health, Inc, 1999-2008.
Physicians Desk Reference, 2010.
MPR, Monthly Prescribing Reference, July 2010.
In my practice, I have found Voltaren very “patient friendly” and easily used with significant benefits. People who are “already taking so many medicines’, people with stomach issues, and very active busy patients find it very useful as analgesic. I have experienced good result in patients with ankle sprains, joint pain, overuse tendonitis and prescribe Voltaren often.
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