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# Diclofenac (Tablet/Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that acts by inhibiting cyclooxygenase (COX-1 and COX-2) enzymes, reducing prostaglandin synthesis. It possesses analgesic, anti-inflammatory, and antipyretic properties.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Mild to moderate pain and primary dysmenorrhea (immediate-release formulations)
## Adult Dosing
* **Osteoarthritis:** 50 mg 2–3 times daily or 75 mg twice daily. Maximum: 150 mg/day.
* **Rheumatoid Arthritis:** 50 mg 3–4 times daily or 75 mg twice daily. Maximum: 225 mg/day.
* **Ankylosing Spondylitis:** 25 mg 4 times daily, plus an extra 25 mg at bedtime if needed. Maximum: 125 mg/day.
* **Acute Pain/Dysmenorrhea:** 50 mg 3 times daily. Maximum: 150 mg/day.
* *Note:* Use the lowest effective dose for the shortest duration.
## Pediatric Dosing
Safety and efficacy have not been established in patients <18 years. Use is generally avoided in pediatric patients unless directed by a specialist under specific institutional protocols.
## Dose Adjustments
* **Renal Impairment:** Avoid in advanced renal disease (CrCl <30 mL/min). Use with caution in mild-to-moderate impairment; monitor closely.
* **Hepatic Impairment:** Reduce dose in mild-to-moderate impairment. Contraindicated in patients with active liver disease.
## Contraindications
* Known hypersensitivity to diclofenac or any NSAID.
* History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Active GI bleeding or peptic ulcer disease.
* Severe heart failure (NYHA Class III/IV).
## Adverse Effects
* **Cardiovascular:** Increased risk of serious thrombotic events, myocardial infarction, and stroke.
* **Gastrointestinal:** Dyspepsia, GI ulceration, bleeding, and perforation.
* **Renal:** Fluid retention, edema, acute kidney injury, hyperkalemia.
* **Hepatic:** Elevated transaminases (ALT/AST).
* **Other:** Hypertension, headache, rash.
## Key Drug Interactions
* **Anticoagulants/Antiplatelets (e.g., Warfarin, SSRIs):** Increased risk of bleeding.
* **ACE Inhibitors/ARBs/Diuretics:** Reduced antihypertensive effect and increased risk of renal impairment (the "triple whammy").
* **Lithium/Methotrexate:** Increases serum concentrations and risk of toxicity.
* **Other NSAIDs/Corticosteroids:** Increased risk of GI toxicity.
## Monitoring
* **Baseline:** CBC, LFTs, renal function (SCr, BUN), and blood pressure.
* **Ongoing:** Periodically monitor LFTs (specifically during long-term therapy), renal function, blood pressure, and signs/symptoms of GI bleeding.
## Clinical Pearls
* **GI Protection:** Consider a concurrent Proton Pump Inhibitor (PPI) in patients at high risk for GI complications.
* **Cardiovascular Risk:** Diclofenac has a higher cardiovascular risk profile compared to some other NSAIDs (e.g., naproxen); use with caution in patients with ischemic heart disease or peripheral arterial disease.
* **Administration:** Take with food or milk to minimize gastrointestinal upset.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice guidelines and prescribing information should be verified with the most current medical literature, facility-specific protocols, and package inserts before making clinical decisions.
