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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 possesses analgesic, anti-inflammatory, and antipyretic properties.
## Primary Indications
* Osteoarthritis (OA)
* Rheumatoid arthritis (RA)
* Ankylosing spondylitis
* Mild to moderate pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis:** 100–150 mg/day in divided doses (e.g., 50 mg TID or 75 mg BID).
* **Rheumatoid Arthritis:** 150–200 mg/day in divided doses (e.g., 50 mg QID).
* **Ankylosing Spondylitis:** 100–125 mg/day (e.g., 25 mg QID plus 25 mg at bedtime).
* **Analgesia/Dysmenorrhea:** 50 mg TID.
* **Max Daily Dose:** 200 mg/day. Use the lowest effective dose for the shortest duration.
## Pediatric Dosing
* **Safety/Efficacy:** Not established for children <18 years. Use is generally off-label or avoided in favor of ibuprofen or naproxen. If prescribed off-label by a specialist, dosing is usually weight-based (e.g., 2–3 mg/kg/day divided TID).
## Dose Adjustments
* **Renal Impairment:** Avoid in advanced renal disease. Use with extreme caution in moderate impairment (monitor serum creatinine).
* **Hepatic Impairment:** Use with caution; monitor liver enzymes. Diclofenac is contraindicated in patients with active hepatic disease.
* **Geriatrics:** Start at the lower end of the dosing range; increased risk of gastrointestinal (GI) toxicity and renal complications.
## Contraindications
* History of asthma, urticaria, or allergic-type reactions to aspirin or other NSAIDs.
* Coronary artery bypass graft (CABG) surgery (perioperative setting).
* Active GI bleeding or peptic ulcer disease.
* Severe heart failure (NYHA Class II-IV).
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, GI ulceration/perforation.
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, or hypertension.
* **Renal:** Fluid retention, edema, acute kidney injury.
* **Hepatic:** Potential for elevated LFTs or rare drug-induced hepatotoxicity.
## 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 increase serum concentrations and toxicity.
* **Corticosteroids/SSRIs:** Increased risk of gastrointestinal ulceration.
## Monitoring
* **Blood Pressure:** Monitor regularly during initiation and dose increases.
* **Renal function:** Baseline and periodic serum creatinine/BUN in high-risk patients.
* **Hepatic function:** Baseline and periodic LFTs (specifically ALT/AST) if long-term therapy is anticipated.
* **GI symptoms:** Monitor for signs of occult bleeding or dyspepsia.
## Clinical Pearls
* **Cardiovascular Risk:** All NSAIDs carry a boxed warning for increased risk of serious cardiovascular thrombotic events.
* **GI Protection:** Consider the addition of a proton pump inhibitor (PPI) or misoprostol in patients with a history of ulcers or those at high risk for GI complications.
* **Administration:** Take with food or milk to minimize gastric irritation.
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*Education Disclaimer: This summary is for informational purposes only. Clinical protocols vary by institution. Always verify specific dosing, safety, and contraindications by consulting current prescribing information (e.g., FDA labels) and institutional pharmacy guidelines before prescribing or administering medication.*
