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## Diclofenac (Oral)
### Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, inflammation, and stiffness associated with various conditions.
### Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
### Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release: 350 mg once daily or 175 mg every 12 hours.
* Delayed-release: 75 mg twice daily or 100 mg once daily. Maximum: 225 mg daily.
* Extended-release: 100 mg once daily. Maximum: 100 mg daily.
* **Acute Pain:**
* Immediate-release: 50 mg every 8 hours as needed. Maximum: 150 mg daily.
* **Primary Dysmenorrhea:**
* Immediate-release: 50 mg three times daily as needed. Maximum: 150 mg daily.
*Note: Specific dosing may vary based on local protocol and formulation.*
### Pediatric Dosing
Dosing in pediatric patients is not well-established and should be based on clinical judgment and physician guidance.
### Dose Adjustments
* **Hepatic Impairment:** Use with caution. Start at the lower end of the dosing range.
* **Renal Impairment:** Use with caution. Monitor renal function.
### 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.
### Adverse Effects
Common adverse effects include gastrointestinal upset, nausea, vomiting, diarrhea, abdominal pain, and headache. Serious risks include gastrointestinal bleeding, perforation, ulceration, cardiovascular thrombotic events, myocardial infarction, stroke, renal toxicity, and hepatic toxicity.
### Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of gastrointestinal bleeding.
* **Other NSAIDs (including aspirin):** Increased risk of adverse effects.
* **Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):** Increased risk of bleeding.
* **Diuretics, ACE inhibitors, Angiotensin II Receptor Blockers (ARBs):** Reduced antihypertensive effect and increased risk of renal impairment.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate levels and toxicity.
### Monitoring
* **Gastrointestinal:** Monitor for signs and symptoms of bleeding (e.g., melena, hematemesis).
* **Cardiovascular:** Assess cardiovascular risk factors.
* **Renal Function:** Monitor serum creatinine and BUN, especially in patients with pre-existing renal disease or those taking concurrent nephrotoxic agents.
* **Hepatic Function:** Monitor liver enzymes, especially in patients with hepatic impairment or those receiving long-term therapy.
### Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
* Avoid concomitant use with other NSAIDs.
* Educate patients on the risks of cardiovascular events and gastrointestinal bleeding.
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**Disclaimer:** This information is intended for educational purposes and does not substitute for professional medical advice. Always consult with a qualified healthcare provider to ensure the information provided is accurate, complete, and appropriate for your specific needs. It is crucial to verify current prescribing information before making any treatment decisions.
