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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation management. It works by inhibiting cyclooxygenase (COX) enzymes, thereby 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. Maximum daily dose: 225 mg.
* **Acute Pain:** 50 mg every 8 hours, as needed. Not to exceed 150 mg in the first 24 hours.
* **Primary Dysmenorrhea:** 50 mg three times daily, as needed. Not to exceed 200 mg on the first day.
## Pediatric Dosing
Dosing in pediatric patients is not well-established for most indications. Refer to specific pediatric guidelines or consult a pediatric specialist.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Lower doses may be appropriate in mild to moderate hepatic impairment. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function.
## Contraindications
* Known hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Active gastrointestinal (GI) bleeding or ulceration.
* History of GI bleeding or perforation related to previous NSAID use.
* Severe heart failure.
* Late pregnancy (third trimester).
## Adverse Effects
* **Common:** Abdominal pain, nausea, dyspepsia, diarrhea, dizziness, headache.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), GI perforation, bleeding, ulceration, renal impairment, hepatic injury, hypersensitivity reactions.
## 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, Angiotensin II Receptor Blockers (ARBs), Diuretics:** Reduced antihypertensive effect; increased risk of renal impairment.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac exposure.
## Monitoring
* Baseline and periodic assessment of renal function (serum creatinine, BUN).
* Baseline and periodic assessment of liver function (ALT, AST).
* Monitor for signs and symptoms of GI bleeding and ulceration.
* Monitor for signs and symptoms of cardiovascular events.
* Monitor for signs and symptoms of hypersensitivity reactions.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Consider gastroprotective agents (e.g., PPIs) for patients at increased risk of GI events.
* Elderly patients and those with pre-existing renal or hepatic disease are at higher risk for adverse effects.
* Avoid concurrent use with other NSAIDs.
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**Disclaimer:** This information is intended for clinical professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and product monographs for complete details. Local protocols and institutional guidelines may influence prescribing decisions.
