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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, reduce inflammation, and lower fever. It works by inhibiting cyclooxygenase (COX) enzymes, which are involved in the synthesis of prostaglandins.
## Primary Indications
* Pain associated with osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
* Mild to moderate pain.
* Primary dysmenorrhea.
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally two to three times daily, or 75 mg orally twice daily. Extended-release formulations: 100 mg orally once daily.
* **Pain and Primary Dysmenorrhea:** 25 mg orally every 4 to 6 hours as needed, or 50 mg orally three times daily.
* **Maximum Daily Dose:** 150 mg for immediate-release formulations. For extended-release, consult specific product labeling.
## Pediatric Dosing
* **Rheumatoid Arthritis:** 2 to 12 years: 1 to 3 mg/kg/day divided into 2 to 4 doses. Maximum daily dose: 3 mg/kg/day (not to exceed 75 mg/day).
* **Pain and Fever:** 6 months to 12 years: 0.5 to 1 mg/kg orally every 6 to 8 hours as needed. Maximum daily dose: 3 mg/kg/day (not to exceed 75 mg/day).
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Dosage reduction may be considered in patients with mild to moderate hepatic insufficiency. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function. Avoid in severe renal impairment.
## Contraindications
* Known hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active gastrointestinal bleeding, ulceration, or perforation.
* History of GI bleeding or perforation related to prior NSAID use.
* History of recurrent ulceration or bleeding.
* Peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Late pregnancy (third trimester).
* Severe hepatic or renal impairment.
## Adverse Effects
* **Gastrointestinal:** Nausea, vomiting, diarrhea, dyspepsia, abdominal pain, constipation, GI bleeding, ulceration, perforation.
* **Cardiovascular:** Increased risk of serious cardiovascular thrombotic events (MI, stroke), hypertension.
* **Renal:** Renal insufficiency, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Dermatologic:** Rash, pruritus, Stevens-Johnson syndrome, toxic epidermal necrolysis.
* **Other:** Dizziness, headache, drowsiness, tinnitus, fluid retention, edema.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Selective Serotonin Reuptake Inhibitors (SSRIs):** Increased risk of GI bleeding.
* **Diuretics and Antihypertensives:** May reduce their efficacy and increase risk of renal toxicity.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **Other NSAIDs/Aspirin:** Increased risk of GI toxicity and other adverse effects.
## Monitoring
* **Renal function:** Creatinine, BUN, especially in patients with pre-existing renal disease or at risk for renal compromise.
* **Hepatic function:** Liver enzymes (ALT, AST), bilirubin, especially in patients with hepatic impairment or those on long-term therapy.
* **Hemoglobin/Hematocrit:** To detect occult GI bleeding.
* **Blood pressure:** Monitor for hypertension.
* **Signs and symptoms of GI bleeding:** Melena, hematemesis, abdominal pain.
* **Signs and symptoms of cardiovascular events:** Chest pain, shortness of breath, weakness, slurred speech.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Administer with food or milk to reduce GI upset.
* Consider gastroprotective agents (e.g., PPIs) in patients with increased risk of GI events.
* Be aware of the potential for delayed wound healing.
* NSAIDs can mask signs of infection.
* Patients with heart failure, hypertension, or edema should be monitored closely due to potential for fluid retention.
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*This information is intended for healthcare professionals. Please consult the current prescribing information and official drug compendia for complete details and to verify dosages and safety information before use.*
