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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg three times daily or 75 mg twice daily. Max: 225 mg/day.
* **Acute Pain:** 50 mg every 8 hours as needed. Max: 150 mg/day.
* **Primary Dysmenorrhea:** 50 mg three times daily as needed. Max: 150 mg/day.
* **Extended-Release Formulations:** Dosing varies by product, typically once or twice daily. Consult specific product labeling.
## Pediatric Dosing
* **Age 2-12 years:** For pain and fever, 1 mg/kg/dose every 8 hours, not to exceed 3 mg/kg/day or the adult maximum dose. For juvenile rheumatoid arthritis, 2-3 mg/kg/day divided into 2-4 doses. Dosing for children should be guided by local protocol and specific product labeling, as formulations and indications can vary.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution; consider lower doses. Not recommended in severe hepatic impairment.
* **Renal Impairment:** Use with caution; consider lower doses. Avoid in severe renal impairment.
## 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.
* [See specific product labeling for additional contraindications, including risks in heart failure, hypertension, and inflammatory bowel disease.]
## Adverse Effects
* **Common:** Abdominal pain, nausea, dyspepsia, diarrhea, headache, dizziness.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), gastrointestinal bleeding, ulceration, perforation, renal toxicity, hepatic toxicity, hypersensitivity reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin) & Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **ACE Inhibitors, ARBs, Beta-Blockers:** Reduced antihypertensive effect and increased risk of renal impairment.
* **Diuretics:** Reduced diuretic effect and increased risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **SSRIs/SNRIs:** Increased risk of bleeding.
## Monitoring
* **GI:** Assess for signs and symptoms of GI bleeding or ulceration.
* **Renal:** Monitor renal function (BUN, creatinine) especially in patients with pre-existing renal disease or those at risk.
* **Hepatic:** Monitor liver function tests (ALT, AST) especially in patients with hepatic impairment or prolonged use.
* **Cardiovascular:** Assess for signs of cardiovascular events.
* **Blood Pressure:** Monitor blood pressure, as NSAIDs can cause or worsen hypertension.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Administer with food or milk to reduce GI upset.
* Extended-release formulations should not be crushed or chewed.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
* NSAIDs can mask signs of infection.
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**Disclaimer:** This information is intended for healthcare professionals. Always verify the most current prescribing information and local protocols before initiating or modifying drug therapy.
