Topical NSAIDs for Aches and Pains

December 5th, 2016. Filed Under: Uncategorized.
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Q: I’ve taken Aleve® or Motrin® for years for my bad knee, but now my stomach burns whenever I take them. My doctor tried me on Celebrex®, which didn’t burn my stomach but didn’t work for me. I’ve already tried Icy-Hot® and capsaicin but they burn my skin. Are there any other creams that could help my joint pain?
Yes. Motrin®, also called ibuprofen, is related to Aleve® (naproxen) and Celebrex® (celecoxib) which are Non-Steroidal Anti-inflammatory Agents, or NSAIDs. In the United States most people take NSAIDs by mouth as tablets, but in the UK and Europe they have used NSAID creams, gels, ointments and sprays for many years.

NSAIDs are very good at treating most types of swelling and pain, whether from a sudden injury like a muscle sprain or strain or a chronic inflammation such as arthritis. Using an NSAID cream or gel directly to your sore muscle or joint can relieve pain and inflammation without the side effects that NSAIDs often cause, like stomach burning, stomach pain, kidney or heart problems. For people who take a blood thinner, using a topical form of NSAID helps avoid an increased risk of bleeding.

You are not alone in noticing side effects from taking an oral NSAID like Aleve® or Motrin®. Many Americans with ulcers, kidney or heart problems could benefit from using an NSAID instead of a dangerous narcotic pain reliever. Sadly, diclofenac is the only commercially available topical NSAID in the United States and it requires a doctor’s visit for a prescription.

With so many other NSAIDs available, why is diclofenac the only one marketed in United States as a cream, gel or spray? I suspect the pharmaceutical companies haven’t bothered to develop or market topical versions of their NSAIDs in America because there’s not enough patent protection to make it profitable.

Another roadblock to the availability of topical forms of NSAIDs is whether it can penetrate the skin. Grinding a medicine up into powder and adding it to a cream or ointment doesn’t guarantee that enough of it will merrily move through the skin to cause a measurable decrease in pain. In some cases, the drug company has decided that the topical version of their NSAID medicine isn’t effective enough to justify the huge investment needed to pursue approval from the Food and Drug Administration (FDA).

Some topical NSAIDs have been shown to ease the acute pain of sprains and strains as well as the chronic pain of osteoarthritis. In September 2012 the Cochran Institute published a review of multiple studies called a meta-analysis on this topic, called Topical NSAIDs for chronic musculoskeletal pain in adults. They collected and evaluated lots of studies done with topical NSAIDs, many of them unpublished work from the files of drug companies. Two NSAIDs stood out as effective in chronic musculoskeletal pain: diclofenac and ibuprofen. Not only that, but diclofenac was shown to be just as effective applied to the skin as in a pill form, and with minimal side effects. Both ibuprofen and diclofenac gel are available without a prescription in the UK and Europe.

While visiting Germany a couple of years ago, I saw Voltaren® gel advertised in the windows of several Apotheks (German pharmacies). The day before we flew home I stopped at a busy Apothek to see if I could purchase some Voltaren®. Pointing at the boxes of gel displayed in their window, I rubbed my elbow and stammered, “Voltaren®, bitte?”

With our daughter Maureen translating, I discovered from the German pharmacist that generic ibuprofen gel had been available in Germany for over 10 years, and neither it nor the Voltaren® gel in the window required a prescription. I walked out triumphantly clutching a tube of each. Too bad the patient information leaflet inside the box was only printed in German.

You can get topical diclofenac in the U.S. in several formulations and brand names, but it is expensive and available only by prescription. Diclofenac comes as Voltaren® 1% gel, applied 4 times daily; Pennsaid® 1.5% solution, applied 3-4 times daily; Pennsaid® 2% solution in a pump applied twice daily; and Flector® 1.3% as a patch applied twice daily. It’s also available as Solaraze® 3% gel for rosacea.

Now, here’s some good news: Voltaren® gel is now available as a generic! This usually means it costs less and will be added to most prescription insurance plans. Check with your doctor for a prescription for generic Voltaren® (diclofenac) 1% gel for your knee pain.

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