One ibuprofen, please! As a pharmacist, you hear this very often, and you should actually ask the question every time: What do you have? Headache? Or knees, back, elbows? And not out of curiosity. But to clarify whether it has to be a tablet or whether external treatment is also an option. Because it is simply better for joint problems.

The ideal idea with painkillers is: you take them and then the problem goes away – and doesn’t come back. Luckily, this is the case for a lot of people when it comes to headaches; you feel much, much better the next day at the latest. Unfortunately not for joint problems. If your knee or hip hurts and you haven’t just fallen, it’s often due to joint wear. And then, unfortunately, the cartilage will not be like new again soon.

Longer treatment is often necessary, and quite a few people do therapy on their own, i.e. without going to the doctor. Because he “only prescribes diclofenac”. But all in all, that’s not a good idea. If only because there are a few interesting treatment options, above all strengthening the muscles that support the joint – and this is best started with a physiotherapy prescription.

But also because painkillers and anti-inflammatories have some serious side effects as soon as you swallow them for a long time, I wrote about that in more detail in my column “Pain, let it go!” reported. Here only briefly again: These are not only stomach and kidney problems, which are always mentioned. Paradoxically, they can also trigger headaches, the “drug-induced headache”. What sounds like a joke at first is unfortunately widespread and associated with a high level of suffering.

And now the good news: When used externally, the side effects mentioned are eliminated – simply because so much less active ingredient circulates in the blood. So you risk at most reddening or burning, for example, where you apply the ointment or gel. But they are no more common than with a placebo. A huge advantage, which is also reflected in the official therapy recommendations: The “topical application” of painkillers and anti-inflammatory drugs should “be considered before oral administration”, according to the guideline recommendations of the professional societies for the treatment of knee osteoarthritis. Or to put it more simply: lubricate first – and only swallow if that doesn’t do enough.

And then what is better, cream or gel? Both diclofenac and ibuprofen are comparatively lipophilic, so they like to stay in fat and do not dissolve well in water. This is why they stay in an ointment or cream that contains fat, rather than in a watery gel, rather than opening up into the skin. A small lab study found that within 30 hours, four times as much active ingredient penetrates the top layer of skin (the stratum corneum) as a cream. Another advantage of the gel: Due to its high water content, there is a slightly cooling effect when applied, which can be very pleasant.

The question remains: ibuprofen or diclofenac? I would always take ibuprofen first. Diclofenac is slightly more effective. But it has a massive environmental problem that “is almost unknown in the medical field,” according to the final declaration of the round table started by the Federal Ministry for the Environment on how to deal with this drug. It’s no better in pharmacy, hardly anyone knows about it, but that’s just my assessment.

Because diclofenac is so stable, it stays in the water and attacks the kidneys of fish, for example. In India, the active ingredient has nearly wiped out certain species of vultures because the birds ate the meat of cattle that had been treated with it. And also in Europe there is a first dead vulture due to diclofenac. The Federal Environment Agency has long advocated the reintroduction of prescription requirements for 25-milligram tablets.

The whole discussion has been going on since at least 2007, when the State Office for Nature, Environment and Consumer Protection of North Rhine-Westphalia (LANUV) named diclofenac as “environmentally relevant in terms of its ecotoxicological effects”. The final declaration mentioned above is from January 2022 and it also states the measures that have been decided, including the intention to provide information to sports associations and start a “consumer campaign”. I haven’t heard anything about it yet, unfortunately.

But anyone who wants to stick with “Diclo” can also do something for the environment: namely, wipe their hands with a paper towel after application and only wash them afterwards. Don’t just crumple the cloth between your fingers thoughtlessly, but proceed with a concept: rub an area of ​​skin, such as the palm of your hand, and then fold the cloth in the middle so that the product-free surface faces outwards. Continue with this on the next area of ​​skin. This is a bit tedious, but according to a study it can significantly reduce wastewater entry by as much as 66 percent. The alternative is disposable gloves. Yes, they make rubbish too. But it’s burned practically everywhere in this country, and diclofenac doesn’t survive that either.

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Note: The column can neither replace individual advice in the pharmacy nor the package insert or medical diagnosis and treatment.