P-120 - A Case Report of an 80-year-old Patient Given Once Daily Diclofenac Epolamine Topical System 1.3% as a Nonsteroidal Anti-Inflammatory Drug Therapy While on an Anticoagulant

Abstract Title: A Case Report of an 80-year-old Patient Given Once Daily Diclofenac Epolamine Topical System 1.3% as a Nonsteroidal Anti-Inflammatory Drug Therapy While on an Anticoagulant


Background: The concomitant use of oral non-steroid anti-inflammatory drugs (NSAIDS) and anticoagulation is associated with an increased risk of gastrointestinal bleeding, stroke, peptic ulcer disease, and major bleeding. This is a significant issue because the elderly have a significantly higher rate of anticoagulant use than younger individuals. At the same time, muscle-strain injuries are especially prevalent in the aging population and recovery from such injuries is age-dependent, making oral NSAIDS an important therapy for robust recuperation in the elderly. Therefore, a safe and effective alternative to oral NSAIDS needs to be available for patients suffering from muscle-strain injuries who are on anticoagulation, and, in particular, the elderly population.

Purpose/Objectives: The primary objective of this clinical work is to present the case of an anticoagulated patient who safely experienced a significant reduction in pain, increase in function, and decreased time to recovery, after the application of once daily diclofenac epolamine topical system 1.3% (Licart), as a topical NSAID, to her acute muscle sprain. NSAIDs, including once daily diclofenac epolamine topical system 1.3%, may increase the risk of bleeding events. Concomitant use of warfarin, other anticoagulants, and antiplatelet agents may increase this risk.


Methods: We performed a search within our electronic medical records of patients who were assigned ICD-10 codes for muscle sprain/strain as well as current use of anticoagulants and NSAIDs.


Results: We identified an 80-year-old lady who had suffered a fall with subsequent low back pain. After a thorough workup, we diagnosed her with lumbar sprain and prescribed her oral diclofenac 25mg every 12 hours. Her pain decreased from 7/10 to 3/10 within a few days. Around the same time, her cardiologist diagnosed her with atrial fibrillation and prescribed her Eliquis (apixaban) - he stopped her oral diclofenac. By the next day, the patient’s pain increased to 7/10 and she returned to our clinic. She refused short-term opioids and had a history of sensitivity to muscle relaxants and neuropathic pain medications. She had tried ice/heat, acetaminophen, and massage, all without relief. We had a discussion with the patient's cardiologist regarding once daily diclofenac epolamine topical system 1.3%, which has a lower systemic absorption when compared to oral NSAID tablets. He agreed to our plan to start once daily diclofenac epolamine topical system 1.3% with her concurrent use of Eliquis.

Within 48 hours of our patient starting diclofenac epolamine topical system 1.3%, her pain decreased from 7/10 to 4/10; 72 hours after starting diclofenac epolamine topical system 1.3%, her pain decreased to 3/10; and 96 hours after starting diclofenac epolamine topical system 1.3%, her pain had decreased to 1/10. She was able to have lower pain scores and improved function to take care her older roommate despite her recent acute injury. More importantly, our patient had experienced no side effects during or after her concurrent use of the anticoagulant Eliquis and once daily diclofenac epolamine topical system 1.3%.

Conclusions/Implications for future research and/or clinical care: Once daily diclofenac epolamine topical system 1.3% may be an option for some patients who concomitantly require oral anticoagulation. This is primarily because diclofenac epolamine topical system 1.3% has a lower systemic exposure when compared to oral NSAIDs. A lower systemic NSAID concentration with concurrent use of anticoagulation may decrease the risk of gastrointestinal bleeding, stroke, peptic ulcer disease, and major bleeding, when compared to higher NSAID concentrations realized with oral NSAIDs. In addition, via its unique delivery system, diclofenac epolamine topical system 1.3% reduces pain within one to three hours after application. Diclofenac epolamine topical system 1.3% has demonstrated to have sustained pain reduction for seven days with once daily use, which further improves recuperation from muscle sprain or strain in the elderly.


References: 1. Penner LS, Gavan SP, Ashcroft DM, Peek N, Elliott RA. Does coprescribing nonsteroidal anti-inflammatory drugs and oral anticoagulants increase the risk of major bleeding, stroke and systemic embolism? Br J Clin Pharmacol. 2022 Nov;88(11):4789-4811. doi: 10.1111/bcp.15371. Epub 2022 Jun 8. PMID: 35484847; PMCID: PMC9796910.
2. Shorr RI, Ray WA, Daugherty JR, Griffin MR. Concurrent use of nonsteroidal anti-inflammatory drugs and oral anticoagulants places elderly persons at high risk for hemorrhagic peptic ulcer disease. Arch Intern Med. 1993 Jul 26;153(14):1665-70. PMID: 8333804.
3. Krittayaphong R, Phrommintikul A, Ngamjanyaporn P, Siriwattana K, Kanjanarutjawiwat W, Chantrarat T, Rojjarekampai R, Kaewcomdee P, Sonkhammee P; COOL-AF Investigators. Rate of anticoagulant use, and factors associated with not prescribing anticoagulant in older Thai adults with non-valvular atrial fibrillation: A multicenter registry. J Geriatr Cardiol. 2019 Mar;16(3):242-250. doi: 10.11909/j.issn.1671-5411.2019.03.004. PMID: 31080466; PMCID: PMC6500563.
4. Baker BA. An Old Problem: Aging and Skeletal-Muscle-Strain Injury. J Sport Rehabil. 2017 Apr;26(2):180-188. doi: 10.1123/jsr.2016-0075. Epub 2017 Jan 17. PMID: 28095141; PMCID: PMC6345250.
5. Shi C, Ye Z, Shao Z, Fan B, Huang C, Zhang Y, Kuang X, Miao L, Wu X, Zhao R, Chen X, Zhang B, Tong R, Hu X, Fu Z, Lin J, Li X, Sun T, Liu G, Dai H, Guo C, Zhang B, Xu T, Wen A, Zuo X, Liu J, Chen X, Li H, Wang J, Luo M, Fan T, Qian Y, Li X, Qiu W, Lin X, Pang Y, Hou Y, Yao D, Kou W, Sun B, Hu C, Xia Y, Zhao M, Zhu C, Li Q, Zhang Y. Multidisciplinary Guidelines for the Rational Use of Topical Non-Steroidal Anti-Inflammatory Drugs for Musculoskeletal Pain (2022). J Clin Med. 2023 Feb 15;12(4):1544. doi: 10.3390/jcm12041544. PMID: 36836078; PMCID: PMC9966446.