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# Diclofenac (Tablet)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that exhibits analgesic, anti-inflammatory, and antipyretic activity. It acts primarily by inhibiting the cyclooxygenase (COX-1 and COX-2) enzymes, leading to reduced prostaglandin synthesis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Primary dysmenorrhea
* Mild to moderate pain
## Adult Dosing
* **Osteoarthritis:** 100–150 mg daily, divided into 2–3 doses.
* **Rheumatoid Arthritis:** 150–200 mg daily, divided into 3–4 doses.
* **Ankylosing Spondylitis:** 100–125 mg daily, divided into 4–5 doses (an additional 25 mg at bedtime may be added if necessary).
* **Maximum Dose:** Generally 150 mg/day for chronic use; some formulations or short-term protocols allow up to 200 mg/day.
## Pediatric Dosing
* **General:** Use of oral diclofenac tablets in children <18 years is generally not recommended or lacks standardized FDA-approved dosing.
* **Juvenile Idiopathic Arthritis (JIA):** In some regions, pediatric dosing is weight-based (2–3 mg/kg/day in 2–3 divided doses); however, safety and efficacy data are limited compared to approved pediatric NSAIDs like naproxen or ibuprofen. Consult local pediatric protocols.
## Dose Adjustments
* **Renal Impairment:** Avoid in severe renal impairment (CrCl <30 mL/min). Use with caution and consider lower doses in mild-to-moderate impairment.
* **Hepatic Impairment:** Avoid in severe hepatic impairment. Monitor liver enzymes closely if long-term therapy is required.
* **Geriatric:** Initiate at the lowest effective dose due to increased risk of gastrointestinal (GI) toxicity and renal complications.
## Contraindications
* Known hypersensitivity to diclofenac or other NSAIDs (including aspirin-induced asthma/urticaria).
* History of CABG surgery (peri-operative pain management).
* Active peptic ulcer disease or GI bleeding.
* Severe heart failure (NYHA Class II–IV).
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, increased risk of ulceration/bleeding.
* **Cardiovascular:** Hypertension, fluid retention, increased risk of myocardial infarction and stroke.
* **Renal:** Acute kidney injury, interstitial nephritis, hyperkalemia.
* **Hepatic:** Elevated transaminases (ALT/AST); rare cases of severe hepatotoxicity.
## Key Drug Interactions
* **Anticoagulants/Antiplatelets (e.g., Warfarin, SSRIs):** Significant increase in bleeding risk.
* **ACE Inhibitors/ARBs/Diuretics:** Increased risk of renal impairment and reduced antihypertensive efficacy.
* **Lithium/Methotrexate:** Diclofenac can decrease renal clearance, leading to potential toxicity.
* **Corticosteroids:** Increased risk of GI ulceration.
## Monitoring
* **GI:** Monitor for signs of bleeding (melena, hematemesis).
* **Renal:** Periodic serum creatinine, BUN, and electrolytes.
* **Cardiovascular:** Regular blood pressure monitoring.
* **Hepatic:** Periodic LFTs if therapy is long-term.
## Clinical Pearls
* **Administration:** Take with food or milk to minimize GI irritation. Swallow tablets whole; do not crush or chew if using extended-release formulations.
* **CV Risk:** Use the lowest effective dose for the shortest duration necessary, especially in patients with existing cardiovascular risk factors.
* **PPI Co-therapy:** Consider co-administration of a PPI in patients at high risk for GI complications.
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*Disclaimer: This information is for educational purposes only. Always verify dosing and contraindications against institutional protocols or the most current prescribing information (e.g., package inserts or clinical resources like Lexicomp/UpToDate) before prescribing or administering medication.*
