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# Diclofenac (Oral) ## Overview Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, tenderness, swelling, and stiffness caused by osteoarthritis and rheumatoid arthritis. ## Primary Indications * Osteoarthritis * Rheumatoid arthritis * Ankylosing spondylitis * Acute pain * Primary dysmenorrhea ## Adult Dosing * **Osteoarthritis:** 150 mg daily, divided into 2 or 3 doses (e.g., 50 mg BID or TID). Maximum: 200 mg/day. * **Rheumatoid Arthritis:** 150-200 mg daily, divided into 2, 3, or 4 doses (e.g., 50 mg TID or QID). Maximum: 200 mg/day. * **Ankylosing Spondylitis:** 100-125 mg daily, divided into 2, 3, or 4 doses. Maximum: 125 mg/day. * **Acute Pain:** 150 mg daily, divided into 2 or 3 doses. Typically used for short durations. * **Primary Dysmenorrhea:** 50 mg TID as needed. May initiate with 100 mg, followed by 50 mg doses if necessary. Maximum: 200 mg/day. Dose and frequency should be individualized to the lowest effective dose. ## Pediatric Dosing Diclofenac oral formulations are generally not recommended for pediatric patients, except in specific circumstances under specialist guidance for juvenile idiopathic arthritis. Dosing varies significantly by age and weight and requires careful monitoring. Consult specific pediatric guidelines. ## Dose Adjustments * **Hepatic Impairment:** Use with caution. Lower doses may be appropriate in mild to moderate impairment. Contraindicated in severe hepatic impairment. * **Renal Impairment:** Use with caution. Consider lower doses and increased monitoring, especially in patients with pre-existing renal disease. Contraindicated in severe renal impairment. * **Elderly:** Increased risk of adverse effects. Use lowest effective dose and monitor closely. ## 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. * Inflammatory bowel disease (active). * Severe heart failure. * Severe hepatic impairment. * Severe renal impairment. * Third trimester of pregnancy. ## Adverse Effects * **Common:** Abdominal pain, nausea, vomiting, diarrhea, constipation, dyspepsia, headache, dizziness, rash. * **Serious:** * **Gastrointestinal:** Ulceration, bleeding, perforation. Risk increases with dose and duration. * **Cardiovascular:** Increased risk of thrombotic events (MI, stroke), hypertension. * **Renal:** Renal papillary necrosis, interstitial nephritis, renal failure. * **Hepatic:** Elevated liver enzymes, hepatitis, jaundice. * **Hypersensitivity:** Anaphylaxis, Stevens-Johnson syndrome, toxic epidermal necrolysis. ## Key Drug Interactions * **Anticoagulants (e.g., warfarin):** Increased risk of bleeding. * **Corticosteroids:** Increased risk of GI bleeding. * **Other NSAIDs/Aspirin:** Increased risk of GI bleeding and other adverse effects. * **SSRIs/SNRIs:** Increased risk of GI bleeding. * **ACE inhibitors, ARBs, Beta-blockers:** Reduced antihypertensive effect; increased risk of renal impairment. * **Diuretics:** Reduced diuretic effect; increased risk of renal impairment. * **Lithium:** Increased lithium levels and toxicity. * **Methotrexate:** Increased methotrexate toxicity. ## Monitoring * **Baseline and periodic monitoring:** Renal function (creatinine, BUN), liver function tests (ALT, AST), complete blood count (CBC), blood pressure. * **GI symptoms:** Monitor for signs and symptoms of bleeding or ulceration. * **Cardiovascular risk factors:** Assess and manage appropriately. ## Clinical Pearls * Administer with food or milk to minimize GI upset. * Use the lowest effective dose for the shortest duration necessary. * Be aware of the increased risk of cardiovascular and GI events, especially in older adults or those with pre-existing risk factors. * Avoid concomitant use with other NSAIDs. * Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications. * Discontinue at the first sign of rash, hepatic or renal dysfunction, or significant GI bleeding. *** *Disclaimer: This information is intended for educational purposes and does not substitute for professional medical advice. Always consult the most current prescribing information and guidelines for definitive patient care decisions.*