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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Pain associated with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis.
* Mild to moderate pain.
* Primary dysmenorrhea.
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release (IR): 150 mg/day divided into 3 doses. Maximum 225 mg/day.
* Delayed-release (DR): 75 mg twice daily or 100 mg once daily. Maximum 200 mg/day.
* Extended-release (ER): 100 mg once daily. Maximum 100 mg/day.
* **Mild to Moderate Pain and Primary Dysmenorrhea:**
* IR: 50 mg three times daily. Maximum 150 mg/day.
* DR: 50 mg twice or three times daily. Maximum 150 mg/day.
* ER: Specific dosing not established for these indications.
## Pediatric Dosing
* **Rheumatoid Arthritis:**
* Children 1 to 12 years: 1-3 mg/kg/day divided into 3-4 doses. Maximum 4 mg/kg/day or 150 mg/day, whichever is less. Use oral drops (15 mg/mL) or suppositories.
* **Other indications:** Dosing not established in pediatric patients.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Consider lower doses.
* **Renal Impairment:** Use with caution. Monitor renal function. Not recommended in severe renal impairment.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active peptic ulceration or gastrointestinal bleeding.
* History of GI bleeding or perforation related to previous NSAID use.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Late pregnancy (third trimester).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, abdominal pain, dyspepsia, headache, dizziness, rash.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), GI bleeding/perforation, renal toxicity, hepatic toxicity, hypersensitivity reactions, Stevens-Johnson syndrome/toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin) and Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **ACE Inhibitors, ARBs, Diuretics:** Reduced antihypertensive effect and increased risk of renal impairment.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate toxicity.
## Monitoring
* Signs and symptoms of GI bleeding.
* Renal function (serum creatinine, BUN).
* Liver function tests (LFTs).
* Blood pressure.
* Signs and symptoms of cardiovascular events.
## Clinical Pearls
* Consider the lowest effective dose for the shortest duration necessary.
* Administer with food or milk to reduce gastric irritation.
* Avoid concurrent use with other NSAIDs.
* Enteric-coated formulations should not be crushed or chewed.
* Use with caution in elderly patients, those with pre-existing renal or hepatic disease, heart failure, or hypertension.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols before making treatment decisions.
