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Diclofenac/Misoprostol

A Review of its Pharmacology and Therapeutic Efficacy in Painful Inflammatory Conditions

  • Drug Evaluation
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Summary

Synopsis

Diclofenac is a well established nonsteroidal anti-inflammatory drug (NSAID) used in the treatment of a variety of painful inflammatory conditions. Although generally well tolerated, diclofenac, like other NSAIDs, is associated with gastrointestinal adverse effects which infrequently can be serious and/or life-threatening. Misoprostol, a prostaglandin E1 analogue, reduces the incidence of NSAID-related ulcers, both gastric and duodenal. The lack of conclusive pharmaco-economic data for misoprostol and the widespread use of NSAIDs makes routine administration of misoprostol difficult to justify for all NSAID users. However, it appears to be an economically warranted approach in the elderly, who are at particularly high risk for NSAID-related gastrointestinal complications.

The fixed combination of diclofenac 50mg and misoprostol 200µg administered 2 to 3 times daily for 4 to 12 weeks has shown equivalent therapeutic efficacy to diclofenac (alone or combined with placebo), piroxicam and naproxen, and was slightly more effective than ibuprofen in clinical studies in patients with a variety of painful inflammatory conditions. No significant differences in therapeutic efficacy were noted between elderly (aged ≥65 years) and younger patients in these studies.

Gastrointestinal adverse events are common with diclofenac and misoprostol, administered alone or in combination. Diarrhoea (presumably attributable to the misoprostol component) appears to be more frequent in diclofenac/misoprostol recipients than in those receiving diclofenac alone or combined with placebo. However, diclofenac/misoprostol recipients had significantly fewer gastroduodenal ulcers at the end of treatment relative to patients receiving comparators in clinical trials. In addition, the types and incidences of adverse events are similar in elderly and younger patients.

Routine ulcer prophylaxis with misoprostol in all NSAID users is not warranted from a pharmaco economic viewpoint. In common with other fixed combination products, dosage flexibility is somewhat compromised with diclofenac/ misoprostol. However, once drug dosages are determined in the individual patient, the fixed combination of diclofenac and misoprostol offers the potential for increased patient convenience and possibly patient compliance, and lower drug acquisition costs than those of the individual drugs used together. Thus, it should be considered a useful treatment option in appropriately selected patients with a high risk for serious NSAID-related gastrointestinal complications who require NSAID therapy.

Overview of NSAID-Associated Gastrointestinal Injury

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely prescribed agents for a variety of painful inflammatory conditions; a significant proportion of users are elderly (aged > 60 years). Although generally well tolerated, this drug class is commonly associated with gastrointestinal adverse effects which can range from discomfort to ulcers (with possible haemorrhage or perforation). Risk factors for serious NSAID-related gastrointestinal complications include advanced age, concomitant use of prednisone, previous NSAID-related gastrointestinal adverse effects, prior hospitalisation for gastrointestinal disorders, increased level of disability and higher NSAID dosages.

Both local and systemic effects are thought to contribute to NSAID-induced gastropathy. Prostaglandins play an important role in a number of gastroprotective mechanisms. Since the therapeutic effects of NSAIDs are largely mediated through inhibition of prostaglandin synthesis, depletion of gastroprotective prostaglandins during NSAID administration may result in gastromucosal injury.

Some attempts have been made to identify relative differences between NSAIDs with respect to their ability to cause gastrointestinal damage; however, all NSAIDs are associated with gastrointestinal adverse effects which at times can be serious and/or life-threatening. One strategy used in an attempt to reduce the incidence of NSAID-associated gastrointestinal damage is coadministration of NSAIDs with drugs that prevent gastrointestinal damage (e.g. misoprostol, H2-receptor antagonists), particularly in patients at high risk of developing complications.

Pharmacodynamic Properties

The anti-inflammatory, analgesic and antipyretic activities of NSAIDs, including diclofenac, are largely the result of their ability to inhibit prostaglandin synthesis. In common with other NSAIDs, diclofenac can induce potentially adverse gastrointestinal, renal and haematological effects associated with prostaglandin inhibition. Of these, gastrointestinal effects are of particular concern.

Misoprostol, a synthetic prostaglandin E1 analogue, has gastric antisecretory and mucosal protective activities. The drug dose-dependently inhibits gastric acid secretion induced by a number of stimuli. The gastric mucosal protective effects of misoprostol are related to several mechanisms including stimulation of bicarbonate and mucus secretion, increased mucosal blood flow, cellular proliferation and migration, and decreased vascular permeability.

Pharmacokinetic Properties

The pharmacokinetic profiles of oral diclofenac and misoprostol are similar whether they are administered concurrently as individual tablets or as a fixed combination formulation. Following multidose oral administration of diclofenac (twice daily for 5 days), both with and without misoprostol, to 24 healthy elderly volunteers, no significant differences in area under the plasma concentration-time curve values for diclofenac were noted between the 2 groups.

Therapeutic Efficacy

Oral diclofenac is a well established NSAID treatment for pain and inflammation, whereas misoprostol has proven antiulcer efficacy, particularly against ulcers caused by NSAID-induced prostaglandin inhibition. The therapeutic efficacy of oral diclofenac 50mg/misoprostol 200µg administered 2 to 3 times daily in a fixed combination formulation appears equivalent to that of the same dosage of diclofenac administered alone or in combination with placebo in patients with a variety of painful inflammatory conditions (e.g. hip/knee osteoarthritis, rheumatoid arthritis, ankylosing spondylitis or acute knee or ankle injury). These results show that the addition of misoprostol does not impair the efficacy of diclofenac.

No significant differences in either physicians’ or patients’ global assessments of disease status were noted between patients treated with oral diclofenac 50mg/ misoprostol 200µg, piroxicam 10mg or naproxen 375mg administered twice daily in patients with osteoarthritis. Similarly, no differences in global assessments of efficacy were noted between diclofenac/misoprostol and diclofenac (administered 2 to 3 times daily) recipients aged >50 years with osteoarthritis, while a significant difference in favour of diclofenac/misoprostol was reported in patients’, but not physicians’, assessment of global efficacy relative to ibuprofen 1200 to 1800mg daily.

Pharmacoeconomic Considerations

From a drug acquisition cost standpoint, if the cost of the fixed combination of diclofenac/misoprostol is less than that of the combined cost of each drug purchased separately, then cost savings will result. Some pharmacoeconomic studies showed misoprostol to be cost saving and cost effective in elderly patients (aged >60 years). However, concerns about the suitability of the models and some of the assumptions used in cost-benefit and cost-effectiveness studies, along with recent data which suggest reduced quality of life in misoprostol recipients and economic benefit with nabumetone relative to ibuprofen plus misoprostol in the elderly, have made it difficult to draw firm conclusions regarding the economic influence of the routine use of prophylactic misoprostol. In addition, available studies have evaluated misoprostol alone and therefore updated studies with the fixed combination are needed to better define the pharmacoeconomic role of diclofenac/misoprostol.

Tolerability

Gastrointestinal effects (abdominal pain, diarrhoea, nausea and vomiting) are the most frequent complaints with both diclofenac and misoprostol. Gastrointestinal bleeding has been reported in <2% of diclofenac recipients in long term (>1 year) clinical trials. Elevations in liver enzyme levels are infrequent during diclofenac therapy but may be marked in ≈1% of patients.

Diarrhoea has been reported in up to 40% (mean 13%) of misoprostol 800 µ/day recipients in controlled clinical trials and necessitates drug withdrawal in up to ≈10% of patients. No adverse CNS, haematological or ophthalmological effects or laboratory test alterations have been directly attributed to misoprostol.

Data from 4 double-blind studies which compared the tolerability of diclofenac/misoprostol with that of diclofenac/placebo (patients received study drugs 2 to 3 times daily for 4 to 12 weeks) indicated that the 5 most commonly reported adverse events were gastrointestinal in nature. Only diarrhoea (presumably due to the misoprostol component) was reported more frequently in diclofenac/misoprostol than in diclofenac/placebo recipients (≈20 vs 12%). Rates of drug discontinuation because of adverse events were similar for diclofenac/ misoprostol (12.6%) and diclofenac/placebo recipients (10.1%). In addition, no differences in the types and incidences of adverse events were noted between elderly (aged ≥65 years) and younger patients.

Tolerability data are available from a large 4-month multicentre study which compared diclofenac/misoprostol with diclofenac alone and ibuprofen in patients aged >50 (mean 65 to 66) years. Although the incidence of dyspepsia, abdominal pain and diarrhoea was significantly higher in the diclofenac/misoprostol group, the overall incidences of adverse events and number of patient withdrawals due to adverse events were similar for the 3 study groups. Mean plasma alanine transaminase levels rose significantly in both diclofenac groups (as a result of a few patients experiencing relatively large increases) but not in the ibuprofen group.

Endoscopic data on the gastrointestinal effects collected from clinical trials showed that patients receiving diclofenac/misoprostol had significantly fewer gastroduodenal lesions at the end of treatment (0 to 4%) than those receiving diclofenac/placebo (4 to 11%), piroxicam (22.1%) or naproxen (17.7%). Analysis of gastroduodenal ulceration rates in 1 study revealed no significant differences between patients aged <60 years and those aged ≥60 years.

Dosage and Administration

The recommended initial and maintenance dosage of the fixed combination of diclofenac 50mg/misoprostol 200µg is 1 tablet 2 or 3 times daily with food for both elderly and younger patients. Dosage adjustment is not necessary in patients with mild to moderate renal impairment but patients with severe renal, cardiac or hepatic impairment or with a history of gastrointestinal disease should be closely monitored. It is recommended that liver function be periodically monitored during long term diclofenac therapy; data from clinical trials suggest that determinations should be performed no later than 8 weeks after initiation of drug treatment.

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    Rick Davis, Yvonne E. Yarker & Karen L. Goa

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Various sections of the manuscript reviewed by: J. Carson, Division of Internal Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA; G. de Pouvourville, Hôpital National de Saint-Maurice, Saint-Maurice, France; R.R. Grigor, Department of Rheumatology, Auckland Hospital, Auckland, New Zealand; A. Isdale, Rheumatology and Rehabilitation Research Unit, University of Leeds, Leeds, England; T. Ishizaki, Division of Clinical Pharmacology, International Medical Center of Japan, Tokyo, Japan; F. McKenna, Rheumatic Diseases Unit at Trafford General Hospital, Manchester, England; P.J. Molloy, Rheumatology Associates of Southeastern Massachusetts, Plymouth, Massachusetts, USA; K. Tsurumi, Department of Pharmacology, Gifu University School of Medicine, Tsukasamachi, Japan; R.P. Walt, Birmingham Heartlands Hospital, Birmingham, England; M. Wolfe, Gastroenterology Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA.

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Davis, R., Yarker, Y.E. & Goa, K.L. Diclofenac/Misoprostol. Drugs & Aging 7, 372–393 (1995). https://doi.org/10.2165/00002512-199507050-00005

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