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# Diclofenac (Oral Tablets)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits cyclooxygenase-1 and -2 (COX-1/COX-2), leading to decreased prostaglandin synthesis. It is available as immediate-release (IR) and delayed-release (DR) tablets.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Management of pain and primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis:** 100–150 mg daily in divided doses (e.g., 50 mg BID or TID).
* **Rheumatoid arthritis:** 150–200 mg daily in divided doses (e.g., 50 mg TID or QID).
* **Ankylosing spondylitis:** 100–125 mg daily (25 mg QID, with an extra 25 mg at bedtime if needed).
* **Maximum Dose:** 200 mg/day. Use the lowest effective dose for the shortest duration.
## Pediatric Dosing
* **Safety/Efficacy:** Not established for clinical use in pediatric patients under 18 years of age. Use is generally off-label and requires institutional protocol verification.
## Dose Adjustments
* **Renal Impairment:** Avoid in advanced renal disease (CrCl <30 mL/min). Use with caution in mild-to-moderate impairment; monitor renal function closely.
* **Hepatic Impairment:** Avoid in severe hepatic impairment. Reduce dose in mild-to-moderate impairment.
## Contraindications
* Known hypersensitivity (including aspirin-induced asthma or urticaria).
* History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Setting of coronary artery bypass graft (CABG) surgery.
* Active gastrointestinal (GI) bleeding or peptic ulcer disease.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, GI ulceration/perforation.
* **Cardiovascular:** Increased risk of myocardial infarction and stroke; fluid retention and edema.
* **Renal:** Acute kidney injury, interstitial nephritis, hyperkalemia.
* **Hepatic:** Elevated transaminases; rare occurrences of drug-induced hepatotoxicity.
## Key Drug Interactions
* **NSAIDs/Aspirin:** Increased risk of GI toxicity.
* **Anticoagulants/Antiplatelets:** Increased risk of bleeding.
* **ACE Inhibitors/ARBs/Diuretics:** Diminished antihypertensive effect and increased risk of renal impairment.
* **Lithium/Methotrexate:** Diclofenac can increase plasma concentrations and toxicity risk.
## Monitoring
* **Baseline/Routine:** CBC, renal function (SCr, BUN), and hepatic function (LFTs).
* **Clinical:** Monitor for signs of GI bleeding (black/tarry stools), cardiovascular events (chest pain, shortness of breath), and peripheral edema.
* **Blood Pressure:** Monitor regularly during initiation and dose titration.
## Clinical Pearls
* **Administration:** Take with food or milk to minimize GI irritation.
* **CV Risk:** Use with extreme caution in patients with established cardiovascular disease or risk factors.
* **Geriatrics:** Use caution; elderly patients have a higher frequency of GI bleeds and renal adverse effects.
* **Hepatotoxicity:** Diclofenac has a higher incidence of transaminase elevations compared to other NSAIDs; monitor LFTs if therapy is long-term.
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**Educational Disclaimer:** This information is for educational purposes only. Clinical practice guidelines vary by institution and region. Always consult current, full FDA-approved prescribing information and institutional protocols before prescribing or administering medication.
