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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation management.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain (mild to moderate)
* Menstrual pain (dysmenorrhea)
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg daily, divided into 2 or 3 doses. Typical starting dose is 50 mg BID or TID.
* **Pain/Dysmenorrhea:** 400 mg to 500 mg every 6 to 8 hours as needed. **Maximum:** 1000 mg/day for acute pain, 150 mg/day for chronic conditions.
* **Enteric-coated tablets:** Usually 25 mg or 50 mg TID or QID.
* **Immediate-release tablets:** Usually 50 mg BID or TID.
* **Extended-release tablets:** Usually 75 mg or 100 mg once or twice daily.
## Pediatric Dosing
Dosing in children is not well-established for oral formulations and is typically reserved for specific indications and dosages determined by a specialist. For instance, some sources cite 1 mg/kg/day divided into 2-3 doses for juvenile idiopathic arthritis, not to exceed adult doses.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. May require lower doses. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function. Avoid in severe renal impairment.
* **Elderly:** Increased risk of GI bleeding, renal events, and cardiovascular events. Use lowest effective dose for shortest duration.
## 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:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, flatulence, headache, dizziness, rash.
* **Serious:** Gastrointestinal bleeding/perforation, myocardial infarction, stroke, hypertension, renal failure, hepatotoxicity, hypersensitivity reactions, Stevens-Johnson syndrome.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin) & Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, diuretics:** Reduced antihypertensive effect, increased risk of renal dysfunction.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased methotrexate toxicity.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
## Monitoring
* **Baseline:** CBC, renal function (SCr, BUN), liver function tests (AST, ALT).
* **Ongoing:** Blood pressure, signs and symptoms of GI bleeding, renal function, liver function. Monitor for cardiovascular risk factors.
## Clinical Pearls
* Consider prescribing a proton pump inhibitor (PPI) or misoprostol for patients at high risk of GI complications.
* Lowest effective dose should be used for the shortest duration necessary.
* NSAIDs carry a boxed warning for cardiovascular thrombotic events, myocardial infarction, and stroke.
* NSAIDs also carry a boxed warning for GI ulceration, bleeding, and perforation.
* Avoid concurrent use with other NSAIDs.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making therapeutic decisions. This information does not replace professional medical judgment.
