The MHRA updated it's guidance on diclofenac in June 2013 after a Europe-wide of review of cardiovascular safety.

Whilst it has long been known that NSAIDs may be linked to an increased risk of cardiovascular events the evidence base has now become much clearer. Diclofenac appears to be associated with a significantly increased risk of cardiovascular events compared with other NSAIDs.

It is therefore advised that diclofenac is contraindicated in patients with the following:

• ischaemic heart disease
• peripheral arterial disease
• cerebrovascular disease
• congestive heart failure (New York Heart Association classification II-IV)

Patients should be switched from diclofenac to other NSAIDs such as naproxen or ibuprofen. This advice does not apply to topical diclofenac.

Studies have shown that naproxen and low-dose ibuprofen have the best cardiovascular risk profiles of the NSAIDs.