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# Diclofenac (Tablet/Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits cyclooxygenase (COX-1 and COX-2) enzymes, reducing prostaglandin synthesis. It is available as immediate-release (IR) and delayed-release/enteric-coated (DR) formulations.
## Primary Indications
Management of osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis. Also used for acute pain and primary dysmenorrhea.
## Adult Dosing
* **Osteoarthritis:** 50 mg 2–3 times daily or 75 mg twice daily.
* **Rheumatoid Arthritis:** 50 mg 3–4 times daily or 75 mg twice daily.
* **Ankylosing Spondylitis:** 25 mg 4 times daily, with an additional 25 mg at bedtime if needed.
* **Maximum Dose:** 150 mg/day for chronic conditions. Use the lowest effective dose for the shortest duration.
## Pediatric Dosing
Safety and efficacy are not established for children <18 years. Use is generally off-label and requires institutional protocol verification. Pediatric use is generally avoided due to renal and gastric safety profiles.
## Dose Adjustments
* **Renal Impairment:** Avoid in advanced renal disease (CrCl <30 mL/min). Use with caution in mild-to-moderate impairment.
* **Hepatic Impairment:** Use with caution; monitor liver enzymes (ALT/AST). Not recommended in severe hepatic impairment.
* **Geriatric:** Increased risk of serious GI and cardiovascular toxicity. Use the lowest effective dose for the shortest duration.
## Contraindications
* Known hypersensitivity to diclofenac or other NSAIDs (including aspirin-induced asthma/urticaria).
* History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Setting of coronary artery bypass graft (CABG) surgery.
* Active GI bleeding or peptic ulcer disease.
## Adverse Effects
* **Cardiovascular:** Increased risk of MI, stroke, and hypertension.
* **Gastrointestinal:** Dyspepsia, gastric ulceration, GI bleeding, perforation.
* **Renal/Hepatic:** Elevated liver enzymes, fluid retention, edema, acute kidney injury.
* **Dermatologic:** Rash, pruritus.
## Key Drug Interactions
* **Anticoagulants/Antiplatelets (e.g., Warfarin, Clopidogrel):** Increased risk of bleeding.
* **ACE Inhibitors/ARBs/Diuretics:** Reduced antihypertensive effect and increased risk of renal impairment.
* **Lithium/Methotrexate:** NSAIDs may decrease clearance, increasing toxicity risk.
* **SSRIs:** Increased risk of GI bleeding.
## Monitoring
* **Baseline/Intermittent:** CBC, renal function (SCr, BUN), LFTs (transaminases), and blood pressure.
* **Signs/Symptoms:** Monitor for occult blood loss, symptomatic GI issues, unexplained weight gain, or fluid edema.
## Clinical Pearls
* **Administration:** Take with food or milk to minimize GI upset. DO NOT crush or chew enteric-coated/delayed-release tablets.
* **CV Risk:** Use with extreme caution in patients with established cardiovascular disease or risk factors for atherosclerosis.
* **Drug Choice:** Avoid concurrent use of multiple NSAIDs due to cumulative toxicity risk.
* **Patient Education:** Advise patients to notify their provider if they experience abdominal pain, black stools, chest pain, or shortness of breath.
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**Educational Disclaimer:** This information is intended for educational purposes only. Always verify dosing, contraindications, and drug interactions against the most current product labeling (FDA-approved package insert) and your institution’s specific clinical guidelines before prescribing or administering medication.
