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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, tenderness, swelling, and stiffness caused by osteoarthritis and rheumatoid arthritis. It is also used for acute pain, menstrual cramps, and migraine treatment.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
* Migraine
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg per day, divided into 2 to 4 doses. Extended-release formulations: 100 mg once daily or 200 mg once daily. Maximum dose: 200 mg per day.
* **Acute Pain:** 100 mg initially, followed by 50 mg every 8 hours as needed. Maximum dose: 150 mg in the first 24 hours.
* **Primary Dysmenorrhea:** 100 mg initially, followed by 50 mg doses as needed to a maximum of 200 mg per day.
* **Migraine:** 50 mg as a single dose. Doses up to 100 mg have been studied.
## Pediatric Dosing
Diclofenac is generally not recommended for children under 16 years of age for chronic conditions like arthritis due to safety concerns. Specific indications and dosing for pediatric use are limited and may vary by formulation and approved indication. Consult current pediatric guidelines for specific age groups and conditions.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. A dose reduction may be considered in patients with mild to moderate hepatic impairment. Contraindicated in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function closely, especially in patients with pre-existing renal disease. Contraindicated in severe renal impairment.
* **Elderly:** Consider lower doses and increased monitoring due to increased risk of adverse effects.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* 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.
* Advanced renal disease.
* Severe hepatic impairment.
* Known risk of bleeding.
## Adverse Effects
* **Common:** Gastrointestinal upset (nausea, vomiting, diarrhea, constipation, abdominal pain), dyspepsia, headache, dizziness, rash.
* **Serious:** Gastrointestinal bleeding, ulceration, perforation; cardiovascular thrombotic events (MI, stroke); renal failure; hepatic failure; anaphylaxis; Stevens-Johnson syndrome; toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of gastrointestinal ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of bleeding.
* **Diuretics, ACE inhibitors, ARBs:** Decreased antihypertensive effect and increased risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
## Monitoring
* **Baseline and periodic:** Renal function (serum creatinine, BUN), liver function tests (ALT, AST), complete blood count (CBC).
* **Ongoing:** Signs and symptoms of gastrointestinal bleeding or ulceration, cardiovascular events, hypersensitivity reactions.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize the risk of serious adverse events.
* Consider gastroprotective agents (e.g., PPIs) for patients at increased risk of gastrointestinal complications.
* Patients with pre-existing cardiovascular disease or risk factors should be closely monitored.
* Discontinue immediately if signs of hepatic or renal dysfunction, or serious skin reactions occur.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making treatment decisions. Drug information can change rapidly.*
