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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce inflammation, pain, and fever.
## Primary Indications
* Pain and inflammation associated with osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
* Acute pain.
* Primary dysmenorrhea.
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150-225 mg per day, divided into 3 doses. Extended-release formulations may be given once or twice daily.
* **Acute Pain:** 225 mg per day, divided into 3 doses.
* **Primary Dysmenorrhea:** Initial dose of 50 mg, followed by 25-50 mg every 6-8 hours as needed. Maximum daily dose: 200 mg.
## Pediatric Dosing
* Diclofenac is generally **not recommended** for children under 16 years of age for its anti-inflammatory indications due to safety concerns and lack of established pediatric dosing.
* For analgesia in children aged 12-16 years with primary dysmenorrhea, a dose of 50 mg may be given initially, followed by 25-50 mg every 6-8 hours as needed. Maximum daily dose: 200 mg.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution; consider a lower dose.
* **Renal Impairment:** Use with caution; monitor renal function. Dose adjustment may be necessary, but specific guidelines are not definitively established for all levels of 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.
* Active peptic ulceration or GI bleeding.
* Severe hepatic or renal impairment.
* Third trimester of pregnancy.
## Adverse Effects
* **Common:** Abdominal pain, nausea, dyspepsia, diarrhea, constipation, elevated liver enzymes.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), GI bleeding, ulceration, perforation, renal toxicity, hepatic failure, hypersensitivity reactions, anaphylaxis, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, heparin) and 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, Methotrexate:** Increased serum levels and toxicity.
* **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac plasma concentrations.
## Monitoring
* **Baseline and periodic assessment of renal function (serum creatinine, BUN).**
* **Baseline and periodic assessment of liver function (AST, ALT).**
* **Monitor for signs and symptoms of GI bleeding or ulceration.**
* **Monitor for signs and symptoms of cardiovascular events.**
* **Monitor for hypersensitivity reactions.**
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Administer with food or milk to minimize GI upset.
* Be aware of the increased risk of cardiovascular and GI events, especially with prolonged use or in patients with risk factors.
* Consider alternative analgesics or anti-inflammatories in patients with significant comorbidities.
* Do not exceed the maximum daily dose.
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*Disclaimer: This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant clinical guidelines for complete and up-to-date details.*
