Sir, Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) with analgesic, anti-inflammatory and antipyretic properties commonly used in low, middle and high-income countries and is available over the counter in most.1,2

It is prescribed for third molar surgery, tooth extraction, root canal treatment, deep cavity preparation and acute dental pain.1,3,4

Bally et al.5 observed that patients taking any dose of NSAIDs for periods of one week or more had increased risk of myocardial infarction.

Use of diclofenac for one to seven days increased the probability of this risk by 99% with greater risks for higher doses and in the first month of use.

Arfe et al.6 also observed that diclofenac was associated with increased risk of hospital admission for heart failure, the risk being doubled when used at very high doses (≥2 defined daily dose equivalents).

Schmidt et al. observed that within a 30-day period of initiation, patients taking diclofenac were exposed to cardiovascular health risks such as atrial fibrillation or flutter, ischaemic stroke, heart failure, myocardial infarction, and cardiac death, when compared to non-use, paracetamol use, and use of other traditional NSAIDs.2

In view of the cardiovascular risks thus identified, diclofenac should be available only on prescription and with adequate written warning but not prescribed for patients with previous myocardial infarction, heart failure and diabetes mellitus.