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Thursday, September 2, 2010

Geriatric Drug Review -- Voltaren

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Voltaren (Diclofenac): Voltaren (Diclofenac) is a NSAID (non-steroidal anti-inflammatory drug) that is excluded from the treatment of osteoarthritis when used alone. In Arthrotec, it is used along with a cytoprotectant called Misoprostol (protects the stomach and duodenum against ulceration), in which case it is an acceptable form of osteoarthritis treatment for those who are at high risk for gastrointestinal ulceration (GI). It is also important to note that Voltaren (Diclofenac), when compared to other NSAID's, has an increased risk of developing NSAID-induced hepatic injury. Therefore, many people on Voltaren (Diclofenac) should have regular liver function tests performed.

Voltaren (Diclofenac) is generally taken as 100-150 mg/day in 2 or 3 divided doses. Side effects include; GI bleeding, abdominal pain, dizziness, anaphylaxis (rare but dangerous), among others.

Voltaren (Diclofenac) may induce toxicity when taken along with Lithium, Digoxin, Methotrexate, or Cyclosporine. Aspirin taken along with Voltaren (Diclofenac) may cause a decrease in the effectiveness of Voltaren (Diclofenac).

Special Geriatric considerations for NSAID use: Peptic and gastrointestinal (GI) ulceration can occur in the elderly at rates as high as 60%. In addition, adverse effects on the central nervous system (CNS) (i.e. confusion, agitation, hallucination) can occur at much lower doses and at much greater frequency in older adults. In order to avoid serious effects on the GI tract and on the CNS, all people taking NSAID's are advised to take the lowest effective dose possible for the shortest amount of time.

Factors that put people at risk for GI ulceration include; age 60 years or older, history of gastric or duodenal ulcers, cardiovascular disease, liver disease, kidney disease, alcohol abuse, and concomitant use of nicotine, corticosteroids, or anticoagulants (i.e. Coumadin, Heparin).

NSAID-induced ulceration is usually gastric in nature. The treatment or prevention of gastric ulceration with concomitant use of H2 blockers (i.e. Cimetidine, Ranitidine), Prilosec (Omeprazole), or Sucralafate is not effective. Nevertheless, H2 blockers are effective in preventing more uncommon NSAID-induced duodenal ulcers. Misoprostol is the only agent proven effective in the prevention of some ulcers.

It is also important to note that all NSAID's, with the exception of COX-2 inhibitors like Celebrex and Vioxx, reduce platelet adhesion. This can have drastic effects on blood clotting time. These NSAID's should be used with caution when taken along with blood thinners like Coumadin (Warfarin), Heparin, Garlic, Ginkgo BIloba, Cayenne, and Bilberry.

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