Positional statement on Diclofenac/ ibuprofen switch

Policy Statement
Oral NSAID (Non-Steroidal Anti-inflammatory Drug) of
choice at ASPH NHS Foundation Trust
Date of Issue
11th January 2012
Review Date:
November 2013
(Unless new published evidence becomes available before
this date OR there is new published national guidance e.g.
Policy statement:
ASPH Drugs & Therapeutics Committee recommends the following in relation to choice of
oral NSAID and cardiovascular (CV) risk:
Ibuprofen in doses of up to 1200mg/day in divided doses is NSAID of choice
Naproxen up to 1g per day in divided doses is second line NSAID of choice.
In cases where ibuprofen and naproxen are either not tolerated or ineffective,
diclofenac may be considered as an option for the management of acute or chronic
inflammatory conditions following discussion with the patient with regard to the risks
and benefits of treatment. This should be documented in the patient’s notes, and
used for the shortest possible course.
Co-prescription of a gastroprotective agent should be considered according to
individual risk factors
Where oral diclofenac is prescribed first line for acute pain eg. post –op, A&E,
trauma, this shall be substituted by ibuprofen or naproxen (if ibuprofen not suitable)
in suitable doses as above. Prescriptions may be changed by pharmacists without
contacting the prescriber, taking into account allergies, adverse drug reaction
information etc.
Where rectal or injectable diclofenac is indicated, this must be used only for the
shortest possible time until conversion to oral ibuprofen/ naproxen is possible. There
are no available rectal/ injectable dosage forms of ibuprofen or naproxen.
In post caesearean section patients who are breast feeding and taking medication
orally, ibuprofen is still first line choice for these patients, however diclofenac (short
term and at the lowest possible dose) is second line as it is safer in breast feeding
than naproxen.
Patients who present with renal colic or renal stones and require admission may be
treated with oral diclofenac for a short time whilst they are inpatient. Patients who are
discharged after assessment in A&E, or after an inpatient stay must be prescribed
ibuprofen first line, naproxen second line. This has been agreed with Urology.
For paediatric patients who require short term oral NSAIDs, ibuprofen is first line,
diclofenac will be second line (as this has more indications than naproxen in
Chronic long term users of diclofenac (eg. rheumatology patients, palliative care
patients) must be reviewed on an individual patient basis and a decision made
accordingly. Any switching by pharmacists without contacting the prescriber does not
apply in these patient groups.
Key Considerations:
NSAIDs are commonly prescribed drugs. All NSAIDs carry the risk of side effects,
which can be serious and life-threatening. The gastrointestinal toxicity of NSAIDs is
well documented and in recent years the risk of unwanted cardiovascular effects
associated with NSAIDs has been publicised by the Medicines and Healthcare
products Regulatory Agency (MHRA) and the National Prescribing Centre (NPC).
In NHS Surrey, the proportion of diclofenac prescribing is relatively high- 48% of oral
NSAID items compared to 37% nationally. This is despite the MHRA advice Oct 2006
on cardiovascular risk with diclofenac and subsequent NPC initiatives starting
November 2007.
Not all traditional NSAIDs carry the same CV risk: diclofenac 150mg/ day appears to
be associated with a similar excess risk to coxibs, whereas low dose ibuprofen
(<1200mg/day) and naproxen 1000mg/day appear to be associated with a lower
risk. Subsequent epidemiological studies reviewed in Drug Safety update reinforce
this and provide further evidence that thrombotic CV risk applies to all NSAID users
irrespective of their baseline risk and not only to chronic users.
All oral NSAIDs (including cox II inhibitors) have analgesic effects of similar
magnitude. However about 60% of patients will respond to any NSAID, those who do
not respond to a particular NSAID may well respond to another. Pain relief starts
soon after the first dose and full analgesia is normally obtained within one week. Antiinflammatory effects may take 3 weeks to achieve.
At ASPH, oral diclofenac stock (including prepacks) has been removed from most
ward areas. Outpatients and A&E prescriptions will be monitored to assess
compliance with prescribing recommendations above.
Date taken to Drugs &
Therapeutics Committee
24th November 2011
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