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# Diclofenac Oral
## Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used for pain and inflammation. It inhibits cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis.
## Primary Indications
* Pain relief
* Inflammation associated with conditions like osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis
## Adult Dosing
* **Immediate-release:** 25 mg to 50 mg orally three to four times daily. Maximum 200 mg per day.
* **Delayed-release:** 25 mg to 50 mg orally three to four times daily. Maximum 200 mg per day.
* **Extended-release:** 75 mg to 100 mg orally once daily. Maximum 100 mg per day (for once-daily formulations). Some extended-release formulations are dosed twice daily. *Consult specific product labeling for exact dosing.*
## Pediatric Dosing
* **Rheumatoid Arthritis:** 2 mg/kg/day divided into 2-4 doses, not to exceed 75 mg/day. *Dosing for other indications and younger children is not well-established.*
## Dose Adjustments
* **Renal Impairment:** Use with caution. No specific dose reduction is typically recommended, but monitor renal function closely, especially in patients with pre-existing renal disease or those at risk for renal compromise.
* **Hepatic Impairment:** Use with caution. Start at the lower end of the dosing range and monitor liver function. May require dose reduction.
## Contraindications
* Known hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of asthma, urticaria, or other 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, vomiting, diarrhea, dyspepsia, headache, dizziness.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), gastrointestinal bleeding, ulceration, perforation, renal toxicity, hepatic toxicity, anaphylaxis, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, heparin, DOACs):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Other NSAIDs/Aspirin:** Increased risk of GI toxicity and potential for synergistic adverse effects.
* **ACE inhibitors/ARBs:** Reduced antihypertensive effect; increased risk of renal impairment.
* **Diuretics:** Reduced diuretic effect; increased risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased methotrexate levels and toxicity.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
## Monitoring
* **Baseline and periodic:** Renal function (BUN, creatinine), liver function tests (ALT, AST), complete blood count (CBC) to assess for anemia or bleeding.
* **Assess for:** Signs and symptoms of GI bleeding (melena, hematemesis), cardiovascular events, and hypersensitivity reactions.
## Clinical Pearls
* Lowest effective dose for the shortest duration should be used to minimize GI and cardiovascular risks.
* Administer with food or milk to reduce GI upset.
* Consider gastroprotective agents (e.g., PPIs) for patients with increased risk of GI complications.
* Avoid concurrent use with other NSAIDs.
* Patient education on recognizing signs of serious adverse effects is crucial.
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*Please verify current prescribing information with the most recent product labeling or a reputable drug compendium before making any clinical decisions.*
