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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation. It works by inhibiting cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Menstrual pain (dysmenorrhea)
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg two to three times daily, or 75 mg twice daily. Maximum: 225 mg/day.
* **Acute Pain:** 50 mg every 8 hours as needed. May initiate with a 50 mg dose, followed by 50 mg every 8 hours for the first day, then 50 mg every 6-8 hours thereafter. Maximum: 150 mg/day for acute pain.
* **Primary Dysmenorrhea:** Initial dose of 50 mg, followed by 50 mg every 8 hours as needed. Maximum: 200 mg/day.
## Pediatric Dosing
* **Juvenile Idiopathic Arthritis:** 1 to 3 mg/kg/day divided into 2 to 3 doses. Maximum: 200 mg/day. Specific dosing depends on local protocol and patient response.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Initiate at the lower end of the dosage range. Severe hepatic impairment is generally a contraindication.
* **Renal Impairment:** Use with caution. Patients with pre-existing renal disease may be at increased risk.
## 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 peptic ulceration or GI bleeding.
* Late pregnancy (third trimester).
## Adverse Effects
* **Common:** Gastrointestinal upset (nausea, vomiting, diarrhea, constipation, dyspepsia), dizziness, headache.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), GI perforation, ulceration, bleeding, renal toxicity, hepatic toxicity, severe skin reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis), anaphylaxis.
## 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, diuretics:** May reduce antihypertensive effects and increase risk of renal impairment.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
## Monitoring
* **Baseline and periodic:** Renal function (serum creatinine, BUN), liver function tests (ALT, AST), CBC.
* **Monitor for:** Signs and symptoms of GI bleeding or ulceration, cardiovascular events, hypersensitivity reactions.
## Clinical Pearls
* Administer with food or milk to minimize GI upset.
* 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 events.
* Be aware of the increased risk of cardiovascular events and GI bleeding, especially with prolonged use or higher doses.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant guidelines before making clinical decisions.
