Diclofenac (Voltaren®) versus Naproxen (Aleve®)
|Brand names||Voltaren®, Cataflam®||Aleve®, Naprosyn®|
• Topical gel
• Transdermal patch
• Ophthalmic solution
• Powder for oral solution
• Oral suspension
|Drug class||Non-steroidal anti-inflammatory drugs (NSAIDs)|
|Phenylacetic acid derivative||Propionic acid derivative|
|Legal status||Non-controlled substance|
|FDA-approved Indications||• Rheumatoid arthritis
• Ankylosing spondylitis
• Primary dysmenorrhea
• Mild to moderate pain
|• Migraine attacks||• Tendonitis
|Off-label uses||• Multimodal analgesic regimen
• Dental surgical procedures
|Mechanism of action||• Inhibit prostaglandin synthesis via non-selective inhibition of COX-1 and 2 COX-2 resulting in reduced formation of prostaglandins, thromboxane, and prostacyclin.|
|• Diclofenac has more selectivity for COX-2 than naproxen.
• Diclofenac appears to inhibit the
lipoxygenase pathways, reducing inflammation by decreasing production of leukotrienes.
• Diclofenac also inhibits arachidonic acid release and stimulates its reuptake
|• Regular administration of naproxen 500 mg BID
can produce an antiplatelet COX-1 effect similar to that of low-dose aspirin
|Therapeutic effects||• Analgesic
• Antipyretic (anti-fever)
Diclofenac accumulates in synovial fluid, which may explain why
its duration of therapeutic effect is considerably longer than its half-life1
Half-life is longer but variable, and may increase
about 2-fold in the elderly because of decline in renal
|Metabolism, Elimination||Diclofenac undergoes first-pass or presystemic elimination. Diclofenac is metabolized in the liver by CYP2C9 to 4-hydroxydiclofenac, the main metabolite, and other hydroxylated forms. After glucuronidation and sulfation, the conjugates are elimination in the urine (65%) and bile (35%). Less than 1% of the drug is excreted unchanged.|| Naproxen undergoes
hepatic metabolism (95%) with 30% of
the drug being metabolized to 6-demethylation. Most of
metabolites, along with unchanged naproxen, are excreted
as the glucuronide or other conjugate. After liver conjugation,
95% of the drug is eliminated by the kidneys.
|Contraindications||• Hypersensitivity to naproxen, diclofenac, or other
• Use during the peri-operative period in the setting of coronary artery bypass graft (CABG) surgery
• Third trimester of pregnancy
|• Active gastric/duodenal/peptic ulcer, active GI bleeding or perforation, regional ulcer, gastritis or ulcerative colitis
• Severe hepatic impairment or active liver disease
|Side effects||• Gastric discomfort, nausea, vomiting, diarrhea, abdominal pain, gastric mucosal damage, flatulence, peptic ulceration
• Dizziness, tinnitus, headache
• Pruritus, rashes
|• Modest elevation of hepatic transaminases occurs
in 5-15% of patients
• Diclofenac elevates risk of cardiovascular adverse effects even at low doses2. Diclofenac is associated with the highest cardiovascular risk among nonselective NSAIDs.
• Diclofenac has a lower risk of GI side effects compared to naproxen
|• Naproxen appears to be risk-neutral with regard to cardiovascular adverse events, even at higher doses2.|
|Pregnancy category||C prior to 30 week s gestation
D starting at 30 weeks gestation
|Drug interactions||• Concomitant use with potassium-sparing diuretics, ACE inhibitors, angiotensin-II receptor antagonists, or other medications that may cause hyperkalemia may result in increased serum potassium levels.|
|Tolerability||Diclofenac appears to be better tolerated than naproxen6, 7.|
|Advantages||• Important advantage of diclofenac is that it has an approximately 10-fold preference to block the COX-2 isoenzyme, which leads to reduced incidence of GI upset, peptic ulcers, and gastrointestinal bleeding compared with other NSAIDs
• Diclofenac is a better choice for patients with ulcers.
|• Over-the-counter formulations
• Naproxen toxicity is relatively uncommon compared to other NSAIDs.
• Naproxen is a better choice for patients with high cardiovascular risk.
Osteo-arthrosis of hip or knee
Diclofenac more effective in relieving pain and stiffness and improving range of joint movements3.
Both naproxen and diclofenac exert similar positive effects on the duration of morning stiffness, bilateral grip strength, and pain4.
Both medications similar therapeutic efficacy in relieving symptoms associated with soft-tissue rheumatism, including pain at rest and on movement, swelling, tenderness, limitation of movement5. However, in patients with diseases affecting the shoulder region diclofenac is more effective.
Diclofenac provides more strong analgesic effect in arthritis6.
Diclofenac provides faster and better analgesia compared to naproxen for acute pain following minor sports injuries8.
Third molar surgery
Diclofenac is better than naproxen for alleviating pain and swelling following extraction of mandibular third molars9.
- 1. Altman R, Bosch B, Brune K, Patrignani P, Young C. Advances in NSAID development: evolution of diclofenac products using pharmaceutical technology. Drugs. 2015 May;75(8):859-77. PubMed
- 2. McGettigan P, Henry D. Cardiovascular risk with non-steroidal anti-inflammatory drugs: systematic review of population-based controlled observational studies. PLoS Med. 2011 Sep;8(9):e1001098. PubMed
- 3. Siraux P. Diclofenac (Voltaren) for the treatment of osteo-arthrosis: a double-blind comparison with naproxen. J Int Med Res. 1977;5(3):169-74. PubMed
- 4. Kajander A, Martio J. Diclofenac sodium (Voltaren) and naproxen in the treatment of rheumatoid arthritis: a comparative double-blind study. Scand J Rheumatol Suppl. 1978;(22):57-62. PubMed
- 5. Valtonen EJ. A comparative short-term trial with Voltaren (diclofenac sodium) and naproxen in soft-tissue rheumatism. Scand J Rheumatol Suppl. 1978;(22):69-73. PubMed
- 6. Siegmeth W, Placheta P. Long-term comparative study: diclofenac (voltaren) and naproxen (proxen) in arthritis. Schweiz Med Wochenschr. 1978 Mar 4;108(9):349-53. PubMed
- 7. Bach GL. Comparative clinical trials with diclofenac sodium and naproxen in rheumatic conditions. Rheumatol Rehabil. 1979;Suppl 2:69-74.
- 8. Colombo G, Giombini A, Pamich T, Peruzzi E, Pisati R. Diclofenac dispersible provides superior analgesia with faster onset of action compared to naproxen granular in patients with acute, painful, minor sports injuries.
- 9. Akbulut N, Üstüner E, Atakan C, Çölok G. Comparison of the effect of naproxen, etodolac and diclofenac on postoperative sequels following third molar surgery: a randomised, double-blind, crossover study. Med Oral Patol Oral Cir Bucal. 2014 Mar 1;19(2):e149-56. PubMed
Published: February 14, 2017
Last updated: February 14, 2017