Diclofenac Topical (arthritis pain)

People who use nonsteroidal anti-inflammatory drugs (NSAIDs) (other than aspirin) such as topical diclofenac (Pennsaid, Voltaren) may have a higher risk of having a heart attack or a stroke than people who do not use these medications. These events may happen without warning and may cause death. This risk may be higher for people who use NSAIDs for a long time. Do not use an NSAID such as topical diclofenac if you have recently had a heart attack, unless directed to do so by your doctor. Tell your doctor if you or anyone in your family has or has ever had heart disease, a heart attack, or a stroke; if you smoke; and if you have or have ever had high cholesterol, high blood pressure, or diabetes. Get emergency medical help right away if you experience any of the following symptoms: chest pain, shortness of breath, weakness in one part or side of your body, or slurred speech.

If you will be undergoing a coronary artery bypass graft (CABG; a type of heart surgery), you should not use topical diclofenac (Pennsaid, Voltaren) right before or right after the surgery.

NSAIDs such as topical diclofenac (Pennsaid, Voltaren) may cause swelling, ulcers, bleeding, or holes in the stomach or intestine. These problems may develop at any time during treatment, may happen without warning symptoms, and may cause death. The risk may be higher for people who use NSAIDs for a long time, are 60 years of age or older, have poor health, smoke, or drink alcohol while using topical diclofenac. Tell your doctor if you have any of these risk factors and if you have or have ever had ulcers or bleeding in your stomach or intestines, or other bleeding disorders. Tell your doctor if you take any of the following medications: anticoagulants ('blood thinners') such as warfarin (Coumadin, Jantoven); aspirin; other NSAIDs such as ibuprofen (Advil, Motrin) or naproxen (Aleve, Naprosyn); oral steroids such as dexamethasone, methylprednisolone (Medrol), and prednisone (Rayos); selective serotonin reuptake inhibitors (SSRIs) such as citalopram (Celexa), fluoxetine (Prozac, Sarafem, Selfemra, in Symbyax), fluvoxamine (Luvox), paroxetine (Brisdelle, Paxil, Pexeva), and sertraline (Zoloft); or serotonin norepinephrine reuptake inhibitors (SNRIs) such as desvenlafaxine (Khedezla, Pristiq), duloxetine (Cymbalta), and venlafaxine (Effexor XR). If you experience any of the following symptoms, stop using topical diclofenac and call your doctor: stomach pain, heartburn, vomiting a substance that is bloody or looks like coffee grounds, blood in the stool, or black and tarry stools.

Keep all appointments with your doctor and the laboratory. Your doctor will monitor your symptoms carefully and will probably take your blood pressure and order certain tests to check your body's response to topical diclofenac (Pennsaid, Voltaren). Be sure to tell your doctor how you are feeling so that the doctor can prescribe the right amount of medication to treat your condition with the lowest risk of serious side effects.

Your doctor or pharmacist will give you the manufacturer's patient information sheet (Medication Guide) when you begin treatment with prescription topical diclofenac and each time you refill your prescription. Read the information carefully and ask your doctor or pharmacist if you have any questions. You can also visit the Food and Drug Administration (FDA) website (https://www.fda.gov/Drugs/DrugSafety/ucm085729.htm) to obtain the Medication Guide.

Nonprescription (over-the-counter) diclofenac topical gel (Voltaren Arthritis Pain) is used to relieve pain from arthritis in certain joints such as those of the knees, ankles, feet, elbows, wrists, and hands. Prescription diclofenac topical solution (Pennsaid) is used to relieve osteoarthritis pain in the knees. Diclofenac is in a class of medications called nonsteroidal anti-inflammatory drugs (NSAIDs). It works by stopping the body's production of a substance that causes pain.

Diclofenac is also available as a 3% gel (Solaraze; generic) that is applied to the skin to treat actinic keratosis (flat, scaly growths on the skin caused by too much sun exposure). This monograph only gives information about nonprescription diclofenac topical gel (Voltaren Arthritis Pain) for arthritis and prescription topical solution (Pennsaid) for osteoarthritis of the knee. If you are using diclofenac gel (Solaraze, generic) for actinic keratosis, read the monograph entitled diclofenac topical (actinic keratosis).

Prescription topical diclofenac comes as a 1.5% topical solution (liquid) to apply to the knee 4 times a day and as a 2% topical solution (Pennsaid) to apply to the knee 2 times a day. Nonprescription (over the counter) topical diclofenac comes as a 1% gel (Voltaren Arthritis Pain) to apply to up to 2 body areas (e.g., 1 knee and 1 ankle, 2 knees, 1 foot and 1 ankle, or 2 hands) 4 times daily for up to 21 days or as recommended by your doctor. Apply diclofenac gel (Voltaren Arthritis Pain) or topical solution (Pennsaid) at around the same time(s) every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use topical diclofenac (Pennsaid, Voltaren Arthritis Pain) exactly as directed. Do not use more or less of it or use it more often or for a longer period of time than prescribed by your doctor. Do not apply the gel or topical solution to any area of your body that your doctor did not tell you to treat.

Apply diclofenac gel (Voltaren Arthritis Pain) or topical solution (Pennsaid) to clean, dry skin. Do not apply the medication to skin that is broken, peeling, infected, swollen, or covered with a rash.

Diclofenac gel (Voltaren Arthritis Pain) and topical solution (Pennsaid) are only for use on the skin. Be careful not to get the medication in your eyes, nose, or mouth. If you do get the medication in your eyes, rinse your eyes with plenty of water or saline. If your eye(s) are still irritated after one hour, call your doctor.

After you apply diclofenac gel (Voltaren Arthritis Pain) or topical solution (Pennsaid), you should not cover the treated area with any type of dressing or bandage and you should not apply heat to the area. You should not shower or bathe for at least 30 minutes after you apply the topical solution (Pennsaid) and for at least 1 hour after you apply the gel (Voltaren Arthritis Pain). Do not cover the treated area with clothes or gloves for 10 minutes after you apply the gel (Voltaren Arthritis Pain), or until the topical solution (Pennsaid) has dried if you are using the topical solution.

It may take up to 7 days before you feel the full benefit from nonprescription topical diclofenac gel (Voltaren Arthritis Pain). If you do not feel arthritis pain relief from this product after 7 days of use, stop use and contact your doctor.

To use topical diclofenac gel (Voltaren Arthritis Pain), follow these steps:

1. Before you use a new tube of diclofenac gel (Voltaren Arthritis Pain) for the first time, open the safety seal that covers the tube and then puncture the opening of the tube using the spiked top of the cap. Do not open the seal with scissors or sharp objects.
2. Place one of the dosing cards from the package on a flat surface so that you can read the print.
3. Using the lines on the dosing card as a guide, squeeze the correct amount of gel onto the dosing card evenly. Make sure the gel covers the entire area marked for your correct dose depending if it is for the upper (hand, wrist, elbow) or lower (foot, ankle, knee) body. Put the cap back on the tube.
4. Clean and dry the skin area where you will apply the medication. Do not apply to skin that has any cuts, open wounds, infections or rashes.
5. Apply the gel to the directed skin areas, using the dosing card to help apply the gel to the skin to up to 2 body areas. Do not apply to more than 2 body areas. Use your hands to gently rub the gel into the skin. Make sure to cover the entire affected area with the gel. Do not apply in same area as any other product.
6. Hold the end of the dosing card with your fingertips, and rinse and dry the card. Store the dosing card until next use, out of reach of children. Do not share the dosing card with another person.
7. Wash your hands well after you apply the gel, unless you are treating your hands. If you are treating your hands, do not wash them for at least one hour after you apply the gel.

To use topical diclofenac 1.5 % topical solution, follow these steps:

1. Clean and dry the skin area where you will apply the medication.
2. Apply the topical solution to your knee 10 drops at a time. You can do this by dropping the topical solution directly onto the knee or by first dropping it onto the palm of your hand and then spreading it onto the knee.
3. Use your hand to evenly spread the topical solution around the front, back, and sides of the knee.
4. Repeat this step until 40 drops of topical solution have been applied and the knee is completely covered with the topical solution.
5. If your doctor has told you to apply the topical solution to both knees, repeat steps 2 to 4 to apply the medication to your other knee.
6. Wash and dry your hands well after you apply the topical solution. Avoid skin contact with other people and the treated knee area.

To use topical diclofenac 2% topical solution (Pennsaid), follow these steps:

1. You will need to prime the pump that contains this medication before you use it for the first time. Remove the cap from the pump and hold the pump upright. Press down the top of the pump four times and catch any medication that comes out on a paper towel or tissue. Throw away the paper towel or tissue in a trash can.
2. When you are ready to apply your medication, wash your hands well with soap and water.
3. Hold the pump at an angle and press down the top of the pump to dispense the medication onto your palm. Press down the top a second time to dispense another pump of medication onto your palm.
4. Use your palm to apply the medication evenly to the front, back, and sides of your knee.
5. If your doctor told you to apply the medication to both knees, repeat steps 3-4 to apply the medication to your other knee.
6. Wash your hands well with soap and water as soon as you finish applying the medication.
7. Replace the cap on your pump and store the pump upright.

This medication may be prescribed for other uses; ask your doctor or pharmacist for more information.

Before using topical diclofenac,

• tell your doctor and pharmacist if you are allergic to diclofenac (Cambia, Flector, Voltaren Arthritis Pain, Solaraze, Zipsor, Zorvolex, in Arthrotec), aspirin, or other NSAIDs; any other medications; or any of the ingredients in topical diclofenac preparations. Ask your pharmacist or check the Medication Guide for a list of the ingredients.
• tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take while using diclofenac topical. Your doctor may need to change the doses of your medications or monitor you carefully for side effects.
• the following nonprescription products may interact with diclofenac topical: aspirin and nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve). Be sure to let your doctor and pharmacist know that you are taking these medications before you start using diclofenac topical. Do not start any of these medications while using diclofenac topical without discussing with your healthcare provider.
• you should know that you should not apply sunscreens, cosmetics, lotions, moisturizers, insect repellents, or other topical medications to areas treated with topical diclofenac. If you have been prescribed diclofenac topical solution (Pennsaid), wait until the area of application is completely dry before applying any of these products or other substances.
• tell your doctor if you have severe diarrhea or vomiting or think you may be dehydrated; if you drink or have a history of drinking large amounts of alcohol, and if you have or have ever had any of the conditions mentioned in the IMPORTANT WARNING section or asthma, especially if you have frequent stuffed or runny nose or nasal polyps (swelling of the lining of the nose); swelling of the hands, feet, ankles, or lower legs; heart failure; or kidney or liver disease.
• tell your doctor if you are pregnant, plan to become pregnant; or are breast-feeding. Diclofenac may harm the fetus and cause problems with delivery if it is used around 20 weeks or later during pregnancy. Do not use diclofenac topical around or after 20 weeks of pregnancy, unless you are told to do so by your doctor. If you become pregnant while using diclofenac topical, call your doctor.
• you should know that this medication may decrease fertility in women. Talk to your doctor about the risks of using topical diclofenac.
• plan to avoid unnecessary or prolonged exposure to real or artificial sunlight (tanning beds or lamps, ultraviolet light) and to wear protective clothing to cover areas treated with topical diclofenac. Topical diclofenac may make your skin sensitive to sunlight.

Unless your doctor tells you otherwise, continue your normal diet.

Apply the missed dose as soon as you remember it. However, if it is almost time for your next scheduled application, skip the missed dose and continue your regular dosing schedule. Do not apply extra diclofenac gel (Voltaren Arthritis Pain) or topical solution (Pennsaid) to make up for a missed dose.

Topical diclofenac may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:

• dryness, redness, itching, swelling, pain, hardness, irritation, swelling, scaling, or numbness at application site
• acne
• stomach pain
• constipation
• gas
• dizziness
• numbness, burning, or tingling in the hands, arms, feet, or legs

Some side effects can be serious. If you experience any of these symptoms or those listed in the IMPORTANT WARNING section, call your doctor immediately:

• hives
• itching
• difficulty swallowing
• swelling of the face, throat, arms, or hands
• unexplained weight gain
• shortness of breath or difficulty breathing
• swelling in the abdomen, ankles, feet, or legs
• wheezing
• worsening of asthma
• yellowing of the skin or eyes
• nausea
• extreme tiredness
• unusual bleeding or bruising
• lack of energy
• loss of appetite
• pain in the upper right part of the stomach
• flu-like symptoms
• dark-colored urine
• rash
• blisters on skin
• fever
• pale skin
• fast heartbeat
• excessive tiredness

Topical diclofenac may cause other side effects. Call your doctor if you have any unusual problems while using this medication.

If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting program online (https://www.fda.gov/Safety/MedWatch) or by phone (1-800-332-1088).

Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and keep it from freezing or excess heat.

It is important to keep all medication out of sight and reach of children as many containers (such as weekly pill minders and those for eye drops, creams, patches, and inhalers) are not child-resistant and young children can open them easily. To protect young children from poisoning, always lock safety caps and immediately place the medication in a safe location – one that is up and away and out of their sight and reach. https://www.upandaway.org

Unneeded medications should be disposed of in special ways to ensure that pets, children, and other people cannot consume them. However, you should not flush this medication down the toilet. Instead, the best way to dispose of your medication is through a medicine take-back program. Talk to your pharmacist or contact your local garbage/recycling department to learn about take-back programs in your community. See the FDA's Safe Disposal of Medicines website (https://goo.gl/c4Rm4p) for more information if you do not have access to a take-back program.

If someone swallows topical diclofenac, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911.

Symptoms of overdose may include the following:

• drowsiness
• lack of energy
• nausea
• vomiting
• stomach pain
• bloody, black, or tarry stools
• vomiting a substance that is bloody or looks like coffee grounds
• slow, shallow, or irregular breathing
• hives
• itching
• difficulty breathing or swallowing
• loss of consciousness

Do not let anyone else use your medication. Ask your pharmacist any questions you have about refilling your prescription.

It is important for you to keep a written list of all of the prescription and nonprescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.

• Pennsaid^®
• Voltaren Arthritis Pain^®