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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. It works by inhibiting cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain (acute, mild to moderate)
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release: 350 mg to 500 mg orally once daily, divided into 2-4 doses.
* Extended-release: 100 mg to 150 mg orally once daily.
* **Acute Pain:**
* Immediate-release: 25 mg orally every 6-8 hours as needed. Do not exceed 75 mg in 24 hours for this indication.
* **Primary Dysmenorrhea:**
* Immediate-release: 50 mg orally three times daily as needed. Alternatively, start with 100 mg orally once daily, followed by 50 mg orally if pain persists. Do not exceed 200 mg in 24 hours.
**Maximum Daily Dose (for all indications combined):** Generally 150 mg for extended-release formulations and 200 mg for immediate-release formulations. Doses up to 225 mg/day have been used in specific rheumatoid arthritis regimens under strict medical supervision.
## Pediatric Dosing
Oral diclofenac is **not generally recommended** for use in children younger than 12 years due to lack of established efficacy and safety data, except under specific specialist guidance (e.g., rheumatology). Limited data exists for specific age groups and indications.
## Dose Adjustments
* **Renal Impairment:** Use with caution. No specific dose adjustment is typically recommended for mild to moderate impairment, but NSAID use should be avoided in severe renal impairment.
* **Hepatic Impairment:** Use with caution. Start at the lower end of the dosage range in patients with mild to moderate hepatic impairment. Monitor liver function tests. Avoid in severe hepatic impairment.
* **Elderly:** Increased risk of adverse effects, particularly gastrointestinal bleeding and cardiovascular events. Use the lowest effective dose for the shortest duration.
## 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.
* Active gastrointestinal bleeding or ulceration.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, occult blood loss, peptic ulceration, GI perforation.
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, and related deaths. Hypertension.
* **Renal:** Acute kidney injury, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Dermatologic:** Rash, pruritus.
* **Other:** Headache, dizziness, fluid retention, edema.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, Beta-blockers, Diuretics:** Diminished antihypertensive effect and increased risk of renal impairment.
* **Lithium:** Increased lithium levels and toxicity.
* **Methotrexate:** Increased methotrexate levels and toxicity.
## Monitoring
* **Renal function:** Baseline and periodically, especially in patients with risk factors.
* **Hepatic function:** Baseline and periodically, especially in patients with known liver disease.
* **Blood pressure:** Monitor for hypertension.
* **Signs of GI bleeding:** Hemoccult stool, melena, hematemesis.
* **Signs of cardiovascular events.**
## Clinical Pearls
* Use the lowest effective dose for the shortest possible duration to minimize risks.
* Consider co-prescription of a proton pump inhibitor (PPI) or misoprostol in patients at high risk for GI complications.
* NSAIDs can mask signs of infection.
* Discontinue diclofenac at the first sign of rash, hepatic, or renal abnormalities, or significant GI adverse effects.
* Available in immediate-release and extended-release formulations, as well as topical and intravenous forms, each with distinct dosing and indications. This information pertains to oral formulations.
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***Disclaimer:** This information is intended for clinical decision-making and should not replace a thorough review of the most current prescribing information, institutional protocols, and individual patient assessment. Always verify drug information with official sources.*
