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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, inflammation, and stiffness.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain (acute and chronic)
* Dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg two to three times daily, or 75 mg twice daily. Maximum daily dose: 225 mg.
* **Acute Pain:** Initial dose 50 mg, followed by 50 mg every 8 hours as needed. Or, 75 mg initially, followed by 75 mg every 12 hours as needed. Maximum daily dose: 225 mg.
* **Dysmenorrhea:** 50 mg three times daily. Maximum daily dose: 200 mg.
* **Extended-release formulations:** Typically 75 mg or 100 mg once or twice daily.
## Pediatric Dosing
Established pediatric dosing for oral diclofenac is not widely available or approved by regulatory agencies. Use in children should be guided by specialist advice and specific product labeling where available. Some sources suggest doses for specific indications, but caution is advised due to limited data.
## Dose Adjustments
* **Renal Impairment:** Use with caution. No specific dose adjustment is typically recommended for mild to moderate impairment, but monitor renal function closely. Avoid in severe renal impairment.
* **Hepatic Impairment:** Use with caution. No specific dose adjustment is typically recommended for mild to moderate impairment, but monitor liver function closely. Avoid in severe hepatic impairment.
* **Elderly:** Increased risk of adverse effects; consider lower doses and closer monitoring.
## Contraindications
* Known 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 gastrointestinal bleeding.
* Inflammatory bowel disease (active).
* Severe heart failure.
* Severe renal or hepatic failure.
* Third trimester of pregnancy.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, vomiting, diarrhea, constipation, abdominal pain, peptic ulceration, GI bleeding.
* **Cardiovascular:** Increased risk of myocardial infarction and stroke. Hypertension. Edema.
* **Renal:** Acute kidney injury, interstitial nephritis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Hematologic:** Anemia, thrombocytopenia.
* **Dermatologic:** Rash, pruritus.
* **Central Nervous System:** Headache, dizziness, drowsiness.
## 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:** Reduced antihypertensive effect, increased risk of renal dysfunction.
* **Diuretics:** Reduced diuretic effect, increased risk of renal dysfunction.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased methotrexate toxicity.
## Monitoring
* **Gastrointestinal:** Signs and symptoms of bleeding or ulceration.
* **Cardiovascular:** Blood pressure, signs/symptoms of MI or stroke.
* **Renal:** Serum creatinine, BUN, urine output.
* **Hepatic:** Liver function tests (ALT, AST).
* **Hematologic:** Complete blood count.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotection (e.g., PPI) in patients with increased GI risk factors.
* Monitor for cardiovascular risks, especially in patients with pre-existing cardiovascular disease or risk factors.
* Avoid concurrent use with other NSAIDs.
* Discontinue immediately if signs of hepatic, renal, or serious cardiovascular events occur.
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***Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and product labeling for complete details, including contraindications, warnings, and adverse reactions, before prescribing or dispensing any medication. Local protocols may dictate specific dosing strategies.*
