Diclofenac is a powerful, yet controversial painkiller.

Diclofenac is a powerful, yet controversial painkiller.


It is already well known that non-steroidal anti-inflammatory drugs (NSAID’s) in general carry a risk to cardiovascular health, and in particular to the heart.

This issue has been thrust back into the spotlight today, by research published in the PLOS Medicine online journal[1][2] that specifically looks at how the powerful painkiller diclofenac is prescribed by medical professionals in 15 global nations.

Over Prescription

The outcome, somewhat alarmingly, is that diclofenac is being overprescribed almost everywhere, even when medical professionals are (or should be) fully aware of the risks carried.  While this in itself raises questions about the medical professional, it also means we should ask ourselves whether we question our doctors enough, or whether we really give due time and regard to information sheets regarding side-effects and possible risks.

After all, the internet has enabled the global population to become adept at ‘self-diagnosis,’ so if we can walk into our local surgery and start telling the doctor what we believe to be wrong with us, surely we can come up with some ideas and queries relating to medication.

Despite the findings, medical experts have advised patients globally that if they have been prescribed diclofenac, they should continue to take it.  Nevertheless, there are certain to be those making appointments over the coming week to ask what the alternatives are.

The issue of diclofenac’s safety is further complicated by the case of rofecoxib, a similar NSAID that was withdrawn in 2004 when concerns were raised in much the same manner as those today.  In Europe, diclofenac is currently subject to a continent-wide review of its safety, in addition to the study detailed here.

While on the face of it the risks associated with diclofenac seem serious, the complications rate of patients prescribed the drug is at most 0.003%.  Yet, in certain patients, that risk level can be substantially higher, which has led for calls from some for the drug to be banned entirely in some countries.  Those with existing heart conditions or whom are known to be at a higher risk of heart attack or stroke will not be prescribed the drug, however there are calls for more to be done to understand which other people diclofenac should be considered off limits to.


Justin Mason, of Imperial College London, when asked about the findings in the report, commented, “I do think there is over prescription of diclofenac.

“There are some particular cases when it is a good option – but there are other painkillers that may be considered safer.

“We need to understand these types of drugs on an individual basis rather than tarnish them all with the same brush.

“There is an argument that diclofenac should be withdrawn from being available over the counter in shops [in the UK, it has been prescription only in the US for some time].”

Another NSAID, naproxen, is widely accepted to be safer than diclofenac, however, as prescribed doses are usually low and only given over a short period, the latter remains the preferred option by many medical professionals.  Naproxen is often prescribed as the alternative for those with underlying heart conditions, although it is listen as an essential medicine in only 27 nations around the world, in contrast to diclofenac, which enjoys the same status in 74.

Further opinion was offered by Maureen Talbot, a respected Senior Nurse at the British Heart Foundation, who said, “Anyone taking these painkillers should be made aware of both their risks, especially of cardiovascular disease and internal bleeding, and benefits in treating debilitating pain such as that caused by arthritis.

“If you are taking these powerful drugs and are worried, discuss your concerns with your GP or pharmacist who will be able to help you decide whether the benefits outweigh the risks.”

Worth It?

While Ms Talbot’s final comment brings us back to the questions we asked ourselves earlier, it seems somewhat obvious that a person with a painful and debilitating medical condition such as arthritis is going to seek out the strongest painkiller, irrespective of the attached risks in many cases.

By placing the onus on the patient to decide, there is a risk of the medical profession abdicating their responsibility to patients, in effect.  Yes, it is a positive step to allow patients to control what they take and decide whether they wish to do so, but the ultimate direction should come from a doctor, surely?  Being prescribed a medication should be seen as a direct instruction that will enable you to manage a condition, not a recommendation.

All of this further complicates our relationships with medical professionals in many respects.  After all, we have already become masters of ‘self-diagnosis,’ often feeling as if we know what our doctor will say before we even visit them.  At the same time, if such studies raise the awareness of associated side effects, not just with regard to NSAID’s, but with all medications, then something positive will come from them.

Ultimately, modern medicine is a question of balancing risk in many respects.  Are we willing to take a risk with one aspect of our health, however small, to deal with a problem elsewhere in our bodies?

Until research is able to point us in the direction of managing side effects down to minimal levels, it is one that will continue to hang over anyone requiring medicines to treat a variety of conditions.

[1] http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001388

[2] http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001389

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