Comparing NSAIDs: Topical vs. Oral?>

Comparing NSAIDs: Topical vs. Oral

by Wellness Letter  

The only topical non-salicylate non-steroidal anti-inflammatory drug (NSAID) approved by the FDA for use in the U.S. is diclofenac, available as prescription gels, patches, and liquids and in different formulations: diclofenac sodium gel (Solaraze, Voltaren, or generic), diclofenac epolamine patch (Flector), and diclofenac sodium topical solution (Pennsaid). Some compounding pharmacies can make topical products from other NSAIDs, including ibuprofen and ketoprofen.

Studies on the effectiveness of topical diclofenac and other NSAIDs have had some design issues and somewhat mixed results, however; as with the OTC products, there is likely at least some placebo effect. Among the study findings:

  • A 2004 meta-analysis of 25 studies, published in BMC Musculoskeletal Disorders, concluded that topical NSAIDs, including diclofenac, were effective and safe for treating chronic musculoskeletal pain for two weeks. But another meta-analysis in BMJ that same year found topical NSAIDs no more effective for osteoarthritis pain than a placebo after two weeks and less effective than oral NSAIDs. The authors concluded that “no evidence supports the long-term use of topical NSAIDs in osteoarthritis.”
  • A 2008 study in BMJ that compared topical and oral ibuprofen for chronic knee pain in older people concluded that “topical NSAIDs may be a useful alternative to oral NSAIDs,” though it also questioned whether either preparation is particularly effective.
  • A 2016 Cochrane Collaboration review concluded that topical NSAIDs (diclofenac and ketoprofen) may provide good pain relief for a minority of people with osteoarthritis, “but there is no evidence for other chronic painful conditions.”

Long-term use of oral NSAIDs has well-known adverse effects, including gastrointestinal irritation and bleeding and an increased risk of heart attacks and stroke. Some research has found a higher incidence of abnormal liver function tests in people taking oral versus topical diclofenac.

Topical NSAIDs, on the other hand, are not absorbed into the blood to the same extent as oral doses, and studies have demonstrated that people have lower peak blood levels of the medications and fewer adverse effects when using topical formulations versus pills. Still, side effects can occur—in some 10 to 15 percent of topical ibuprofen users, one paper noted—mostly skin reactions (such as rashes, dryness, and itching), and it’s possible that if the medication is absorbed well enough to have benefits, then it’s also having some systemic effect.

If you’re at risk for a stroke or a heart attack, topical products may in particular be a better choice than oral NSAIDs. The same is true if you have a sensitive digestive system or gastrointestinal condition such as GERD (gastroesophageal reflux disease) and want to avoid side effects, such as indigestion, nausea, and abdominal pain, that can occur with oral NSAIDs. It’s probably best not to combine topical NSAIDs with oral NSAIDs; there’s no evidence demonstrating that this provides better pain relief, and it increases the risk of side effects.

Jeanine Barone contributed to this article.

This article first appeared in the UC Berkeley Wellness Letter.