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1840891 tn?1431551393

Topical NSAID?

All the regulars here know me, but a brief intro for others: I 'm 58, have had HCV since 1984 and was dx'd with compensated cirrhosis around 2004. I'm now near the end of my third tx, a 48-week bout of triple tx with Incivek. I've been UND and had normal liver enzymes since week 8 and I'm now on week 46.

Here's my new question: I've had autoimmune arthritis for decades now, but in just the last year I've also developed osteoarthritis in both thumbs. It's very painful and quite debilitating. I complained to my PCP about how I couldn't take NSAID's, and she suggested I try Voltaren gel, a topically applied NSAID. She said if used as directed only very minute amounts would be absorbed into the general circulation. I googled the drug and immediately found an alarming FDA safety report at http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm193047.htm, which notes post-marketing reports of drug- induced hepatoxicity, some leading to complete failure of the liver. I decided to ask my hepatologist before trying this medication. I truly expected him to say no, but instead his email reply was simply "okay to use."

I've since tried this gel cautiously, in about half the recommended amount and only 1-2 times per day rather than every 4 hours. Even in such small doses I can definitely note some pain relief and improved mobility, so I really want to be able to continue using it, however, in spite of my hepatologist's okay, I keep worrying about whether I might add to my existing liver damage. I would love to hear from anyone who can offer some info such as how most hepatologists feel about the use of this gel (or any other topical NSAID) in cirrhotics. I just have this lingering doubt that my hepatologist tends to be a little bit too relaxed about some things – it does seem to take quite a lot to actually alarm him. Thanks!
19 Responses
Avatar universal
Hi, I don´t know much on this topic, but this questions was already made before:

http://healthquestions.medhelp.org/diclofenac-hepatitis

Maybe one of the guys that answered it can help you.

Best regards,
163305 tn?1333672171
I wish I could help you with this one.

The only experience I can relate is about when I had decompensated cirrhosis.
The ascites showed up while I was swimming a lot in the ocean. None of my doctors thought the salt water would affect my ascites, even when they put me on a low salt diet. They were wrong. If I got in the ocean, my belly swelled up. Our skin is porous and it does absorb. That is my observation. Obviously it's not as potent as taking something orally but it still can affect you.
This would be my concern about the topical ointment you're using.

Since your hepatologist thinks it's fine, maybe doing what you're doing, using it in the smallest amounts and only when needed, would be fine.
2147300 tn?1369693288
Funny thing, on my first tx in 2003 my GI was adamant about taking Tylanol. No acetaminophen.  

Today, my same GI says ok for the tylanol. He is more relaxed, more experienced.  Maybe the warning is standard like acetaminophen was in the day?

Got to say the nasty.......What about the roid tx?
766573 tn?1365170066
Yes!
http://www.cks.nhs.uk/osteoarthritis/evidence/supporting_evidence/pharmacological_treatments/topical_nsaids


I used to love Volteran but it strung when I applied it. I use the 5% Ibuleve gel on my hands and knees. I have been buying it on eBay.UK for years. I was stunned when I moved back to the states and no one had ever heard of it. Products like Deep Heat (Mentholatum) smell good and the heating sensation feels OK for about five minutes but I never (ever) experienced functional relief with concoctions like that.


(The gel & the mousse are great: don't hassle with the spray)

http://www.ebay.co.uk/sch/i.html?_trksid=p5197.m570.l1313&_nkw=Ibuleve&_sacat=0
Plus there are some other places that sell it.

http://www.netdoctor.co.uk/seniors-health/medicines/ibuleve.html
http://www.medicine.ox.ac.uk/bandolier/booth/painpag/topical/topkin.html
http://www.ncbi.nlm.nih.gov/pubmed/8361400
253566 tn?1219683299
After reading all the warnings I was also VERY concerned about Voltaren gel (I got the !%).

I also started with a very small amount for shoulder pain and only during strenuous use (such as taking a full bath with a fear of my shoulder giving out while I tried to get in and out of the bath...).

But Boy! some of those warnings were pretty scary - like internal bleeding in the elderly!!! WTF!!!

I do keep it on my shelf for stock-when needed (but really hope that my condition doesnt get worse and I wont need anything.

Best of luck,
frank
223152 tn?1346981971
I wish I could help but I have never used the product.  When I drank, and I was never a big drinker, but when I had over 2 beers or glasses of wine, which was overdoing for me, I could feel the sluggishness the next morning -- I would not call it a hangover, but a foggy feeling.  I attributed it to my liver not being able to process the toxins.  Is it possible that you can observe how you feel the day after you have used the voraten gel?  Perhaps you can gauge how much you can use it.

I am glad you are so close to completion and get these drugs out of your system.

Note to OH -- I find that very interesting about your swimming in the ocean and the salts coming thru the pores.  There is a new place in my town that offers a salt wellness therapy.  I guess the room is filled with salt and you breathe in the salt airs and it is healing.  I was curious about it because I know salt does heal wounds, but I guess I won't be trying that!

bean
163305 tn?1333672171
The only reason the salt water was a problem for me was because I already had decompensated cirrhosis. As you know, in that condition we are supposed to eat a very very low sodium diet. Of course, water probably got into my mouth too.
If you don't have decompensated cirrhosis, I wouldn't worry about the salts :)
1840891 tn?1431551393
Thank you, all of you. I just wish I could find anything that deals directly with the issue of using topical NSAIDS on cirrhotic patients. Google didn't return anything that actually talked about the two issues together. Recently there was a thread here talking about acetaminophen versus NSAIDs, but it was all oral stuff. The manufacturer of Voltaren gel states that the recommended dose results in only 6% the systemic absorption compared to an oral dose of the same drug, so it seems true that I won't absorb very much of it, and even less if I'm taking half the recommended dose at half the frequency, but I STILL wish I could hear a few other hepatologists say it is safe. It is tempting to just say no to the drug, but these darn thumbs get so painful that I can't even pick up my pills at times and I frequently have to use two hands to pick up a water glass for a drink  just because I can't get enough force with my thumb to grasp anything. It is getting ridiculous!
446474 tn?1446351282
As always, it depends on how extensive your cirrhosis is and any bleeding and coagulation issues you have. Varices, low platelet count, INR (which measures vitamin k and other clotting factors). Remember the topical drug still has the warnings that apply to the oral form even though absorption in the blood supply is less.

General warning for person with cirrhosis who take NSAIDs from the Mayo Clinic web site.

"Avoid NSAIDs in persons with cirrhosis because of the potential for hematologic and renal complications." If you have portal hypertension along with your cirrhosis NSAIDs can cause bleeding. In addition "Avoid NSAIDs in persons with platelet defects or thrombocytopenia". NSAIDs can interfere with blood clotting and cause internal bleeding or the inability to stop bleeding.

"This medicine may also cause serious effects on the stomach or intestines, including bleeding or perforation (forming of a hole). These conditions can be fatal and can occur without warning while you are using diclofenac topical, especially in older adults."

http://www.drugs.com/mtm/diclofenac-topical.html

"Some NSAIDs, particularly sulindac (Clinoril) and diclofenac, showed higher rates of hepatic injury and transaminase elevation more than three times the upper limit of normal compared with placebo. However, even in large systematic reviews, clinically significant outcomes, such as hospitalization or death, were rare. NSAIDs do carry some risk in persons with impaired hepatic function. There have been case reports of NSAIDs causing idiosyncratic liver toxicity in persons with underlying hepatitis C, with marked elevations in liver enzymes to more than 10 times the upper limit of normal. There are also indirect deleterious effects of NSAIDs in persons with underlying liver impairment. Many persons with cirrhosis have impairment of coagulation, and NSAIDs increase bleeding risk by additionally inhibiting platelet function. NSAIDs also decrease prostaglandin-mediated blood flow to the kidneys, leading to an increased risk of renal failure in persons with cirrhosis."

If you are going to use diclofenac, I would take the risk into your calculation and do as the FDA safety warning indicates. Monitor transaminases during its use.

"In postmarketing reports, cases of drug-induced hepatotoxicity have been reported in the first month but can occur at any time during treatment with diclofenac. Postmarketing surveillance has reported cases of severe hepatic reactions, including liver necrosis, jaundice, fulminant hepatitis with and without jaundice, and liver failure. Some of  these reported cases resulted in fatalities or liver transplantation.

***Physicians should measure transaminases periodically in patients receiving long-term therapy with diclofenac. The optimum times for making the first and subsequent transaminase measurement are not known. Based on clinical trial data and postmarketing experiences, transaminases should be monitored within 4 to 8 weeks after initiating treatment with diclofenac."***

I would suggest you weigh the risk vs the benefit of the drug. Again keeping in mind you risk of bleeding due to varices, low platelets ad other clotting factors that will be unique to you. Is it worth risking decompensation or worse even though there may be a small chance of it happening? Only you can decide.
If you do decide to use the drug it seems only right that you would want to be monitored closely for signs of liver damage as the warning states. Blood levels of transaminases will indicate problems occurring before you ever feel it unless you have a sudden bleed.

Good luck!
Hector

253566 tn?1219683299
Looks like Hector has really put it all forward for you.

From the benefits and your conclusion/desire (if it was me I would keep testing a smaller & smaller amount pushing the envelope for a dose as long as I could for my second dose and keep testing until you are comfortable and still getting a decent benefit from the dose.

I do hope that you are comfortable with a doc who will be just as concerned with your situation - and you can ask that you have tests run to make sure that this new med is not messing up anything and you continue testing for a period of time, take a break from testing (if all goes well) then after a couple of months start retesting again to see that all is as it should be.

I dont use the stuff as constant as you will be but would like to hear about your feeling on stuff...

Another possibility my doc had for me was to blend up something to her formula but of course my medicaid insurance wouldnt cover it and an ounce was pretty expensive... you could talk to your doc to see if he can write up an original blend that would take care of the pain and be less toxic to your liver.
766573 tn?1365170066
I get what you are asking. A topical might very well have the same effects however that does not necessarily mean it is metabolised the same way.
As the Netdoctor link points out:
When used properly and topically (i.e., locally)
When ibuprofen is applied to the skin (topical application) it is absorbed through the skin into the underlying tissues, where it reduces pain and inflammation in the local area

Over or misused:
Ibuprofen is absorbed less into the bloodstream from preparations that are applied to the skin than from preparations that are taken by mouth (see end of factsheet), however absorption can still occur, particularly if large amounts are used on large areas.

_______________

However since you have Cirrhosis and you are using a topical NSAID then maybe you can work backward to determine the extent the same process happens with topical application as it would oral application.

I mentioned topical Ibuprofen so perhaps you could start out reading about the disposition of (oral) ibuprofen in patients with liver cirrhosis.
http://www.ncbi.nlm.nih.gov/pubmed/8403739
and ask your Hepa the extent this would happen (if at all) topically.
____________

I appreciate how limited the choice of meds that must be available to a cirrhotic however I am wondering if moderate use of the topical is completely out of question. And to be honest I would leave that to your Hepa or a Compounding Pharmacologist ~ especially if you genuine find relief.

My heart just leaped when I read how sore your thumbs get. This is not my thumb but it is how mine felt after three solid days of yard work clipping and pruning:

http://www.buzzle.com/img/articleImages/357090-59116-26.jpg

I woke up and it felt like I was wearing mitts. The Ibuleve worked faster than an ice pack and taking the day off. That is why I can appreciate wanting to use an efficacious topical on the spot in question rather than take a pill and hope it systemically gets the job done.

I would pursue this since effective pain management is a must when you need it and there has to be some decent options even though you have Cirrhosis.
766573 tn?1365170066
Wow I just re-read that bit about your Hepa. Topical NSAIDs aren't really that common in the US so I can appreciate wondering how much thought he put in to your question.

Plus, lots of doctors have no idea the extent a transdermal (or topical) application of certain meds differs from the oral version. I found that out when I used the Emsam patch (selegiline transdermal system) rather than ill itself.
1840891 tn?1431551393
Thanks again, all of you. My cirrhosis seems to be very well-compensated, with no varices or ascites. They don't even seem to be able to find any signs of portal hypertension. I would even doubt my dx of cirrhosis if it had been the usual type of needle biopsy, but mine was a wedge biopsy done by a top liver transplant surgeon while removing a choledochal cyst and re-arranging all the connections of my intestines. I'll never forget how he informed me of the cirrhosis – his lip curling in disgust as he described the outward appearance of my liver as being "every bit as bad as the ones we discard during transplants." He was really trying to get me prepared for the worst, and as a result I keep being pleasantly surprised whenever I get back good test results.

As I've been fretting over this and gathering all of your opinions and advice, I've settled into a bit of a schedule of using the stuff in a very small quantity and only once a day, at bedtime. It helps me sleep a little better and helps me avoid a repeat performance of dropping a full glass of water all over the bed when trying to take a drink during the night, and I also wake up with a little less pain. I doubt if my hepatologist would decide on his own to order the test to monitor my liver enzymes, but he probably will if I ask him to, and my PCP would absolutely do that for me. I am also going to hold onto a little hope that maybe my thumbs will start to feel better sometime after EOT. If they stay this bad for more than another six months I will consult with the local hand-surgery wizard regarding joint replacement surgery rather than take full doses of even a topical NSAID. I will always wonder whether I would have even ended up cirrhotic in the first place if it weren't for all the years I was taking maximum doses of every strong NSAID on the market in an attempt to control the pain and inflammation from my autoimmune arthritis – which was probably caused by my HCV in the first place. At that time my hepatologist was not at all concerned with the meds I was being given by my rheumatologists, but in hindsight I think he should have been - or maybe none of them knew enough back then (the 1990's) to be concerned with NSAIDs, I don't know exactly when they figured that out. Thanks again you guys, you are the BEST!
766573 tn?1365170066
Just thought I would post this here since it is a related topic.
_________
From Medscape Medical News
http://www.medscape.com/viewarticle/771202?src=mpnews
Topical NSAIDs May Be a Better Choice for Elderly With OA

September 18, 2012 — Topical diclofenac is about as effective as oral diclofenac in knee and hand osteoarthritis (OA), is probably as effective as other oral NSAIDs, and might be a safer choice for elderly patients and others at risk for gastrointestinal adverse effects, according to an intervention review published online September 12 in the Cochrane Database of Systematic Reviews.

Sheena Derry, PhD, and colleagues from the University of Oxford in the United Kingdom based their conclusions about topical NSAIDs on a review of randomized, double-blind studies with placebo or active comparators in which at least a single treatment was a topical NSAID used to treat chronic pain caused by OA, and in which treatment lasted at least 2 weeks. The analysis included data from 7688 participants in 34 studies, 23 of which compared a topical NSAID with placebo.

"Topical NSAIDs were significantly more effective than placebo for reducing pain due to chronic musculoskeletal conditions," the authors conclude. "Direct comparison of topical NSAID with an oral NSAID did not show any difference in efficacy." Topical NSAIDs were associated with more local adverse events, such as mild rash, but with fewer gastrointestinal adverse events than oral NSAIDs.

For topical diclofenac, the number needed to treat (NNT) for at least 50% pain relief vs placebo was 6.4 for diclofenac solution and 11 for diclofenac gel formulation. There were insufficient data to calculate NNTs for other individual topical NSAIDs.

"The results presented here show clearly that high quality large studies demonstrate efficacy of topical NSAIDs in 12 week studies, with NNTs similar to those of oral NSAIDs," the authors write.

Coauthor R. Andrew Moore, from the Pain Research Unit at Oxford University, told Medscape Medical News that in view of the low NNT for diclofenac solution, it would be reasonable for clinicians to view that formulation as good first-line therapy for hand or knee OA, especially in elderly patients.

"It is what [the National Institute for Health and Clinical Excellence] in the UK suggest in their excellent OA guideline," Dr. Moore said. "This [is] nothing new for us, but then we have been looking at the evidence on topical NSAIDs for almost 20 years.... [And] what we said then is true now. Truer, perhaps."

Experimental data suggest that creams are generally less effective than gels or sprays, according to the authors. "One of the features of topical NSAIDs is that formulation has the potential to play a big part in efficacy," Dr. Moore said.

The authors write, "It is probable that topical NSAIDs exert their action both by local reduction of symptoms arising from periarticular structures, and by systemic delivery to intracapsular structures. Tissue levels of NSAIDs applied topically certainly reach levels high enough to inhibit cyclooxygenase-2. Plasma concentrations found after topical administration, however, are only a fraction (usually much less than 5%) of the levels found in plasma following oral administration. Topical application can potentially limit systemic adverse events by increasing local
effects, and minimizing systemic concentrations of the drug. We know that upper gastrointestinal bleeding is low with chronic use of topical NSAIDs."

Roy Altman, MD, professor emeritus, Division of Rheumatology, University of California, Los Angeles, reviewed the study for Medscape Medical News. "I think this Cochrane review was well done and carefully reported," Dr. Altman said. "The data are convincing. Their results are concordant with our results from the literature and consistent with our recommendations of the American College of Rheumatology guidelines published earlier this year. I suspect topical NSAIDs will eventually be approved for over-the-counter use, as they are in Europe. That will dramatically increase their use."

This study was supported by Oxford Pain Research in the United Kingdom. Dr. Deery and one coauthor have received research support from charities, government, and industry sources at various times. One coauthor has received research, consulting, and lecture fees from various pharmaceutical companies related to analgesics and other healthcare interventions. Dr. Altman has disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online September 12, 2012. Abstract
1840891 tn?1431551393
Thanks Idyllic! I had to stop using it because it started causing a very itchy rash, but I'm hoping my skin will tolerate it better after the ribavirin starts to clear from my system. The ribavirin all by itself has caused a constant minor rash - not too itchy, but lots of ugly red bumps everywhere, including my face :-(  , and I imagine my skin is pretty easily provoked right now. Things have got to be getting better now!
766573 tn?1365170066
Hey I just read in your other post about your rash. I never (ever) promote non-HCV related things on here but I wish you could have the chance to at least try the 5% Ibuleve gel. It is fast absorbing and (to me) non-irritating. I liked the diclofenac but it stung like crazy.

Ever since I moved back to the states I have been buying it on eBay. I know people have mixed feelings about shopping on eBay but there are other chemists that ship directly from the UK on the Internet since the product is not prescription. I think for both information and sellers you have to log into Google UK instead of regular Google.

I kind of have an amateur hobby with hand puppets so I have very strong wrists and hands. Plus I do a lot of work in general my hands. I was devastated for the first time ever when I could not use scissors or lawn shears.


I don't want to hijack your thread but I have done a lot of my own research about things I can do to mitigate repetitive motion injury, inflexibility and inflammation. I just wanted you to know that while I do not have cirrhosis I can more than empathize with what you must be going through.
1840891 tn?1431551393
Thanks, I will look for it online!
317787 tn?1473362051
Thank you so much for starting this thread.
I tried this over a one week period, it worked really well for my knee pain though I think I over did it.
This is all very interesting I appreciate the thread very much

For me it would depend on the amount of pain, if it is really bad, I would use it in small amounts keeping in mind all of the above info

It is like taking Ibuprofen for me.  I only use it when the pain is very bad and I have to go someplace.

I have also used "Lidoderm Patches"  they are lidocaine patches that were first invented by a doctor for his wife who had shingles.  Now I know people who use it for back pain, knee and foot pain, etc.

Good luck
Dee
Avatar universal
I too have Hep C, I am a Nurse as well and have been dealing with many issues myself.  Autoimmune problems d/t HCV are the biggest pain in the arse but I am racking them up like I am winning at all the Carnival Games of life.  

I just want to say, not knowing if you have made this connection yet - but have you tried to alter your diet and cut out ALL Nightshades?  I have, and the difference is astonishing.  I was diagnosed with RA about a year before I was told I had HCV, which only came about d/t gallstones and an almost fatal episode of pancreatitis.  It was caught early, was biopsied at Stage 1 Grade 0, or vice versa.  Anyway, point is diet is so important to helping with ALL health issues.

My health has improved dramatically since I did my own research and investigations into all medical advice both Eastern and Western, Holistic, Naturopathic, Homeopathic (not big on my list), etc...

Try it, I have and it helps so much.  I am not even close to great, but I am better than I was and that is great all by itself.  

The first truly helpful book I bought after 2 years of heavy research and talking with many Holistic approach, Western Medicine Professionals was a guide to better health through eating well/cookbook called "PRACTICAL PALEO" written by Diane Sanfilippo, BS, NC.  She is a chef, and a Registered Dietician who suffered for years with crippling AUTOIMMUNE Disorders and Disease.

Her book is NOT a "diet".  It is a change in lifestyle to help you feel the best for your particular health issues or concerns.  There is something for all in this book; Autoimmune, Endocrine, GI, Thyroid (which my HCV has ruined), MS, Fibromyalgia, Chronic Fatigue, Neurologic Health, Heart Heath, Cancer Recovery, Fat loss, Athletic Performance...Wow, it is a lot but many things crossover.  She goes in depth about food allergies to which I have discovered I suffer from, as well as food intolerances (my lack of a gallbladder attests to both).

That is my addition, you may or may not read this.  If you do, GOOD LUCK.  I know it is not a CURE, but it certainly makes a difference for the better.
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