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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. It inhibits cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg three times daily, or 75 mg twice daily. Maximum 225 mg/day.
* **Acute Pain:** 50 mg every 8 hours as needed. Maximum 150 mg/day.
* **Primary Dysmenorrhea:** 50 mg every 8 hours as needed, or 100 mg initially, followed by 50 mg every 8 hours as needed. Maximum 200 mg/day.
* **Delayed-release formulation:** Typically 50 mg two to three times daily.
* **Extended-release formulation:** Typically 100 mg once daily or 75 mg twice daily.
Dosing may vary based on specific formulation and local protocols.
## Pediatric Dosing
Safety and efficacy in pediatric patients are not established for all indications. For juvenile idiopathic arthritis, specific dosing guidelines may exist and should be followed per institutional protocol.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. No specific dose adjustment, but monitor closely for adverse effects.
* **Renal Impairment:** Use with caution. No specific dose adjustment, but monitor closely for adverse effects. Consider alternatives in severe renal impairment.
## 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 perforation.
## Adverse Effects
* **Common:** Abdominal pain, nausea, dyspepsia, diarrhea, constipation, flatulence, elevated liver enzymes.
* **Serious:** Gastrointestinal bleeding/perforation, cardiovascular thrombotic events (myocardial infarction, stroke), renal toxicity, hypertension, hepatic failure, hypersensitivity reactions, bronchospasm.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, direct oral anticoagulants):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of gastrointestinal bleeding.
* **ACE inhibitors, ARBs, diuretics:** Reduced antihypertensive effect, increased risk of renal impairment.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **Other NSAIDs, Aspirin:** Increased risk of adverse effects, particularly gastrointestinal.
## Monitoring
* **Renal function:** Baseline and periodically, especially in patients with pre-existing renal disease or those at risk.
* **Hepatic function:** Baseline and periodically, especially in patients with liver disease or those on long-term therapy.
* **Blood pressure:** Regularly monitor for hypertension.
* **Signs and symptoms of GI bleeding:** Stool guaiac, signs of anemia.
* **Signs and symptoms of cardiovascular events.**
## 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 concurrent use with other NSAIDs.
* Patients with cardiovascular risk factors should use diclofenac with caution.
* Discontinue use if any serious adverse event occurs.
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*Please verify this information against the most current prescribing information and institutional protocols before use.*
