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# Diclofenac (Oral)
## Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used to relieve pain, tenderness, swelling, and stiffness in osteoarthritis and rheumatoid arthritis.
## Primary Indications
* Pain and inflammation associated with osteoarthritis
* Pain and inflammation associated with rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg three times daily, or 75 mg twice daily.
* **Acute Pain:** Starting dose 50 mg, followed by 50 mg every 8 hours as needed. Alternatively, 75 mg initially, followed by 75 mg every 12 hours as needed.
* **Maximum Daily Dose:** 150 mg (for acute pain or patients over 65 years). For osteoarthritis and rheumatoid arthritis, the maximum recommended daily dose is generally 150 mg, although some guidelines suggest up to 200 mg for short-term management of severe symptoms, but this increases risk.
## Pediatric Dosing
* **Juvenile Rheumatoid Arthritis:** Doses range from 1 mg/kg/day to 3 mg/kg/day in divided doses. Maximum daily dose is 150 mg. Specific dosing depends on age and weight and should be determined by a healthcare provider.
## Dose Adjustments
* **Renal Impairment:** Use with caution. No specific dose adjustment is typically recommended for mild to moderate impairment, but NSAIDs should be avoided in severe renal impairment.
* **Hepatic Impairment:** Use with caution. Start with a lower dose and monitor liver function closely. Avoid in severe hepatic impairment.
* **Elderly:** Increased risk of adverse effects. Use the lowest effective dose for the shortest duration necessary.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of bronchospasm, asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Known hypersensitivity to diclofenac.
* Active peptic ulceration or gastrointestinal bleeding.
* Severe hepatic or renal insufficiency.
* Third trimester of pregnancy.
## Adverse Effects
* **Common:** Abdominal pain, nausea, vomiting, diarrhea, constipation, dyspepsia, flatulence, headache, dizziness, rash, edema.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), gastrointestinal perforation, ulceration, bleeding, severe hepatic reactions (hepatitis, jaundice), renal failure, anaphylaxis, 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 gastrointestinal ulceration and bleeding.
* **Selective Serotonin Reuptake Inhibitors (SSRIs):** Increased risk of gastrointestinal bleeding.
* **Diuretics and Antihypertensives:** NSAIDs can reduce their efficacy and increase the risk of renal toxicity.
* **Lithium and Methotrexate:** Increased serum levels and toxicity.
* **Ciclosporin and Tacrolimus:** Increased risk of nephrotoxicity.
## Monitoring
* **Gastrointestinal:** Monitor for signs and symptoms of ulceration and bleeding.
* **Cardiovascular:** Assess risk factors and monitor for signs of cardiovascular events.
* **Hepatic:** Liver function tests (ALT, AST) should be monitored periodically, especially with long-term use or in patients with pre-existing liver disease.
* **Renal:** Renal function (creatinine, BUN) should be monitored periodically, especially in patients with risk factors for renal impairment.
* **Blood Pressure:** Monitor blood pressure, as NSAIDs can cause hypertension.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration possible to minimize risks.
* Administer with food or milk to reduce gastrointestinal upset.
* Consider gastroprotection (e.g., PPI) in patients at high risk for GI events.
* Be aware of the increased risk of cardiovascular events and gastrointestinal bleeding associated with NSAID use.
* Discontinue NSAIDs at the first sign of rash, hepatic dysfunction, or gastrointestinal bleeding.
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**Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always verify current prescribing information with the official drug monograph or a reliable drug database before making treatment decisions.
