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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce inflammation and pain.
## Primary Indications
* Pain and inflammation associated with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis.
* Mild to moderate pain.
* Primary dysmenorrhea.
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150-200 mg per day divided into 2-3 doses. Extended-release formulations may be dosed once or twice daily. Maximum daily dose: 200 mg.
* **Mild to Moderate Pain:** 100-150 mg per day divided into 2-3 doses. Immediate-release formulations can be dosed as 50 mg every 8 hours as needed. Maximum daily dose: 150 mg.
* **Primary Dysmenorrhea:** 100 mg initially, followed by 50 mg every 8 hours as needed. Maximum daily dose: 150 mg.
## Pediatric Dosing
* Dosing for children is not well-established for most oral formulations and should be guided by local protocol and specialist consultation. Some studies suggest use for juvenile idiopathic arthritis, but specific recommendations vary.
## Dose Adjustments
* **Renal Impairment:** Use with caution. Avoid in severe renal impairment.
* **Hepatic Impairment:** Use with caution. Avoid in severe hepatic impairment.
* **Elderly:** Increased risk of adverse events. Use lowest effective dose.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active gastrointestinal bleeding or perforation.
* History of NSAID-induced GI bleeding or perforation.
* Severe hepatic or renal impairment.
* Heart failure.
* Third trimester of pregnancy.
## Adverse Effects
* **Common:** Gastrointestinal upset, nausea, dyspepsia, abdominal pain, diarrhea, constipation, headache, dizziness.
* **Serious:** Gastrointestinal bleeding/perforation, cardiovascular thrombotic events (MI, stroke), renal toxicity, hepatic toxicity, hypersensitivity reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis, exacerbation of asthma.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, Beta-blockers:** Reduced antihypertensive effect, increased risk of renal impairment.
* **Diuretics:** Reduced diuretic effect, increased risk of renal impairment.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate levels and toxicity.
## Monitoring
* **Renal function:** Monitor serum creatinine and BUN, especially in patients with risk factors.
* **Hepatic function:** Monitor LFTs, especially with long-term use or pre-existing liver disease.
* **Gastrointestinal symptoms:** Counsel patients on signs of bleeding.
* **Cardiovascular risk factors:** Assess and monitor.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Consider gastroprotective agents (e.g., PPIs) for patients at high risk of GI bleeding.
* Avoid concurrent use with other NSAIDs.
* Patients with cardiovascular disease risk factors should be carefully assessed before initiating therapy.
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*Disclaimer: This information is intended for clinical use and does not replace professional medical advice. Always consult the most current prescribing information and guidelines before making any treatment decisions.*
