Topical non-steroidal anti-inflammatory drugs (NSAIDs), including diclofenac, are established options for localized musculoskeletal pain, with guidelines supporting their use in knee osteoarthritis, broader osteoarthritis management and acute non-low-back musculoskeletal injuries. For selected indications, topical diclofenac can be highly effective and is generally well tolerated when used as indicated. It provides local analgesic and anti-inflammatory activity with substantially lower systemic exposure than oral NSAIDs, which may be particularly relevant for older adults and people with gastrointestinal, cardiovascular, renal or polypharmacy-related risk factors. As an NSAID, topical diclofenac should nevertheless be used in accordance with product labeling.These clinical benefits sit alongside environmental considerations. Diclofenac may enter wastewater via excretion, and for topical products, through handwashing, wash-off from treated skin, and improper disposal. National exposure estimates suggest that topical formulations can make an important contribution to diclofenac entering wastewater and surface waters, although estimates are setting-specific and depend on assumptions about use, wash-off and wastewater removal.This commentary considers the clinical value of over-the-counter (OTC) topical diclofenac alongside environmental evidence and uncertainties relevant to responsible use. Integrated evidence comparing analgesic options across clinical outcomes, patient safety, environmental burden and substitution effects remains limited, and the net consequences of treatment substitution cannot currently be reliably assessed. Some practical measures can reduce diclofenac release through specific point-of-use pathways, although their uptake and population level impact require further evaluation.Topical diclofenac therefore provides a useful case study for responsible, pharmacist-guided OTC self-care in musculoskeletal pain management. In the authors' opinion, the available evidence and remaining uncertainties call for proportionate stewardship: maintaining clinically appropriate OTC access to topical diclofenac while avoiding unnecessary use and supporting label-consistent treatment, patient education, and feasible measures to reduce avoidable environmental release, alongside formulation and delivery innovation.
OBJECTIVE The approved indication of cladribine tablets has recently been expanded in the United Kingdom for the treatment of all adult patients with active relapsing multiple sclerosis. This analysis assessed the cost-effectiveness of cladribine tablets from the perspective of the National Health Service in patients with active relapsing-remitting multiple sclerosis (RRMS). METHODS A cohort-based Markov model with 11 health states (10 disability states plus death) was developed. In addition to best supportive care without disease-modifying therapy (DMT), 12 recommended DMTs were included as comparators to cladribine tablets over a 50-year horizon. Treatment effects were modelled using hazard ratios for 6-month confirmed disability progression (CDP); relapses and drug-related adverse events were modelled via annualized relapse rates and event probabilities. Associated costs (inflated to 2023 pounds sterling) and quality-adjusted life year (QALY) losses were discounted at 3.5% annually. Sensitivity analyses were conducted. RESULTS Cladribine tablets were dominant (i.e. less costly and more effective) vs ponesimod, ocrelizumab, ofatumumab, dimethyl fumarate, diroximel fumarate, and teriflunomide in pairwise comparisons. Over a lifetime horizon, the model predicted discounted cost-savings with cladribine tablets vs high-efficacy comparators (ponesimod, ocrelizumab, and ofatumumab). In most scenarios, the cost-savings resulted from lower lifetime drug acquisition costs due to the unique fixed course posology of cladribine tablets, in addition to delayed disease progression. Sensitivity analyses supported the base case that cladribine tablets are cost-effective vs ponesimod, ofatumumab, and ocrelizumab; the main source of uncertainty was related to the large credible intervals associated with 6-month CDP. CONCLUSIONS This economic analysis demonstrated that cladribine tablets are a cost-effective treatment option for patients with active RRMS.
