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Diclofenac: also harmful for the environment

 Outlook  Diclofenac, a drug with widespread presence in the environment, has well­-demonstrated environmental toxicity. Another reason not to choose diclofenac.
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Diclofenac carries a greater risk of adverse effects than other nonsteroidal anti-inflammatory drugs (NSAIDs), in particular an increase in cardiovascular deaths, without any greater efficacy; hence its use should be avoided (1). It also has more harmful effects on the environment than other NSAIDs (2).

Drugs and their metabolites are found in the environment when they are not sufficiently removed by sewage treatment after their urinary excretion, or when they have been discarded directly into waste water (3-5).

Diclofenac was detected in 29% of more than 30 000 samples of surface water collected in France between 2007 and 2018. Its concentration is generally reduced by only 20% to 50% by the sewage treatment process (5).

Diclofenac has been detected in various plant and animal species, and in fresh and coastal waters in many countries. Its toxicity, particularly renal, has been demonstrated in trout, to the extent that it has been blamed for their depletion in Swiss rivers (6).

Diclofenac is also toxic to scavenging birds (6). In the Indian subcontinent, where bovine carcasses are left for vultures, one vulture species almost disappeared in the first decade of the 21st century, before recognition of the role of diclofenac led to banning its use in animals in 2006 (2,6,7).

Use of diclofenac in veterinary medicine is prohibited in many European countries (5). It has been authorised in Spain since 2013, and led to the death of a vulture in the Pyrenees in 2021 (7).

According to the French Agency for Food, Environmental and Occupational Health and Safety (ANSES), the available data are not sufficient to establish a risk to human health in France at the levels found in water destined for human consumption (5).

The Stockholm region publishes a list of drugs recommended for its population. Diclofenac is excluded because of its adverse effects, both for humans and the environment (2). Anti-inflammatory drugs such as ibuprofen and naproxen do not carry the same risk of human or environmental harms. This is also the case for paracetamol (2,8).

For many drugs, their impact on the environment has not yet been documented, but it could become a criterion in the choice between drugs. In the meantime, protection of the environment is another reason for not using diclofenac.

References  1- Prescrire Editorial Staff "Towards better patient care: drugs to avoid in 2023" Prescrire Int 2023; 32 (245): 50-53. 
2- Janus Region Stockholm "Diclofenac". janusinfo.se accessed 2 February 2023: 3 pages. 
3- Prescrire Rédaction "La pollution des eaux par les médicaments" Rev Prescrire 2007; 27 (284): 460-464. 
4- Brignon JM and Gouzy A "Diclofenac" Ineris 2012: 57 pages.
5- Anses "Avis de l'Agence nationale de sécurité sanitaire de l'alimentation, de l'environnement et du travail relatif à l'évaluation des risques sanitaires liés à la présence de diclofénac dans les eaux destinées à la consommation humaine" 2019: 59 pages.
6- Scientific Committee on Health and Environmental Risks "Diclofenac EQS dossier 2011": 26 pages. 
7- "First evidence of a vulture killed by veterinary diclofenac in Spain - will the Spanish government and the EU act after this smoking gun?". 4vultures.org accessed 27 February 2023: 5 pages. 
8- Prescrire Rédaction "Douleur nociceptive chez un adulte" Premiers Choix Prescrire, updated January 2022: 6 pages.

©Prescrire 1 November 2023

Source: "Diclofenac: also harmful for the environment" Prescrire Int 2023; 32 (253): 276-277. Free.

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"Towards better patient care:
drugs to avoid in 2023"
Prescrire Int 2023;
 32 (245): 50-53.

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