Topical NSAIDs Offer Joint Pain Relief 

If you have arthritis in just a couple of your joints, you may not need to expose yourself to the risks of oral nonsteroidal anti-inflammatory drugs (NSAIDs) to get some relief. A topical NSAID, like other kinds of topicals, can be rubbed on the skin over sore joints to relieve pain, without the stomach upset or cardiovascular risks of oral medication.

What Are Topical NSAIDs?
First approved in the United States in 2007, topical formulations of diclofenac — the only topical NSAID product commonly available in the U.S. — are available as gels, liquids and patches. Until 2020 it was available only by prescription, but can now be purchased over the counter. Different strengths are available for different purposes. 

The American College of Rheumatology recommends topical a NSAID as a first treatment for osteoarthrtis (OA) pain, especially of the knees. And authors of a 2021 systematic review and meta analysis in The Physician and Sportsmedicine conclude, "It should be recommended to patients as a first-line conservative management for OA of the knee."

However, a 2016 Cochrane review looked at 39 studies with 10,631 participants and found that only about 10% more people get OA pain relief from topical diclofenac than from placebo. So they may not provide sufficient relief for everyone, but it's a good idea to try them before oral medications, and they are a good option for those who can't or don't want to take oral NSAIDs.

What Is Available?

• Diclofenac sodium 1% gel (Voltaren Arthritis Pain, now available as an OTC). 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.
• 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 You?
These gels, liquids or patches may work for you if:

• You have arthritis in smaller joints. Topical NSAIDs 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 stomach upset. 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 slather it on multiple joints and exceed the total recommended dosage.

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