Topical NSAIDs: A Safer Option

Nonsteroidal anti-inflammatory drugs (NSAIDs) come with potential risks. Topical versions may be an alternative.

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If your arthritis treatment plan includes an oral nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Motrin, Advil) or naproxen (Aleve), you may be concerned about the risks with these drugs.

“Systemic NSAIDs carry a risk of cardiovascular and kidney issues, stroke, bleeding and ulcers,” says Meredith Konya, MD, Staff Physiatrist in the Department of Orthopaedic Surgery at Cleveland Clinic. “The risk increases with the duration of treatment,” she explains.

If you have osteoarthritis in only a few joints, you may find pain relief in a safer form-topical NSAIDs. “The risks are still there with topical application, but they are significantly reduced,” says Dr.Konya.

What Are Topical NSAIDs?

A topical medication is applied directly to the skin. In the case of arthritis, it goes over the painful joint. The drug penetrates the skin, enters the joint, and reduces the pain signals in the joint.

The level of drug entering the bloodstream is much lower than when the NSAID is taken by mouth. “Topical NSAIDs reduce the systemic exposure by almost 90 percent,” says Dr. Konya. This minimizes the risk of harmful sideeffects.

The topical NSAIDs available in the United States contain the drug diclofenac, and they require a prescription. Diclofenac is available in three topical formulations: gel, liquid and patch.

Topical Choices

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Diclofenac gel (Voltaren Gel) can be used to treat pain from osteoarthritis in the hands, wrists, elbows, knees, ankles and feet. It may be applied four times daily. The liquid formulation (Pennsaid), which can be used for osteoarthritis of the knee, is applied twice daily. The patch (Flector Patch) is placed over the painful joint. It should be changed every 12 hours. Without insurance, the patch can be expensive, at over $100 for 10patches.

A review of several clinical studies, which was published in the Cochrane Database of Systematic Reviews (April 2016), found that Voltaren Gel is particularly effective. “In this review, 60 percent of patients got 50 percent relief with topical NSAIDs,” says Dr. Konya. This was similar to the pain relief from oral NSAIDs and better than the placebo.

Topical NSAIDs are usually very well tolerated. However, approximately one out of 20 people experience a mild, temporary skin reaction, such as rash, redness, dryness oritchiness.

Is It Right for You?

The American College of Rheumatology and the Centers for Disease Control and Prevention recommend topical NSAIDs as one of the initial treatments for arthritic pain.

“Topical NSAIDs are best for people with only a few painful joints,” says Dr. Konya. If you apply the NSAID to several joints you may exceed the recommended dosage and increase the risk of side effects. “People with arthritis in multiple joints are better off with an oral NSAID or acetaminophen unless there’s a reason they shouldn’t take them,” says Dr. Konya.

Topical NSAIDs are particularly good for hand, knee or elbow arthritis. Because these joints are close to the surface of the skin they are more suited to topical treatment than deeper joints like the hip or shoulder.

“Topical NSAIDs should always be used with caution in people with cardiovascular or kidney disease,” says Dr. Konya. You should not use topical NSAIDs if you have had asthma, hives, or other allergic-type reactions after taking aspirin or other NSAIDs. Also, topical NSAIDs should not be used after open heart surgery, such as coronary artery bypass graft surgery.

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