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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg daily, divided into 2 or 3 doses (e.g., 50 mg three times daily or 75 mg twice daily). Maximum: 225 mg daily.
* **Acute Pain:** Initial dose of 50 mg, followed by 50 mg every 8 hours as needed. Alternatively, 75 mg twice daily. Maximum: 200 mg daily.
* **Primary Dysmenorrhea:** Initial dose of 50 mg, followed by 50 mg three times daily as needed. Maximum: 200 mg daily.
* **Delayed-release tablets:** Typically dosed 2-3 times daily.
* **Extended-release tablets:** Typically dosed once daily.
Specific dosing regimens may vary based on local protocols.
## Pediatric Dosing
* **Rheumatoid Arthritis:** Children 2 to 15 years: 1 to 3 mg/kg/day divided into 2 to 4 doses. Maximum: 200 mg daily. (Limited data, use with caution).
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Dose reduction may be considered in mild to moderate hepatic impairment. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. 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.
* Concomitant use with other NSAIDs, including COX-2 inhibitors.
## Adverse Effects
* **Common:** Abdominal pain, nausea, dyspepsia, diarrhea, headache, dizziness, rash.
* **Serious:** Cardiovascular thrombotic events (myocardial infarction, stroke), gastrointestinal bleeding, ulceration, perforation, renal toxicity, hepatic toxicity, exacerbation of hypertension, fluid retention, edema, anaphylactic reactions.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, heparin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of gastrointestinal bleeding.
* **SSRIs/SNRIs:** Increased risk of gastrointestinal bleeding.
* **ACE inhibitors, ARBs, Diuretics:** Reduced antihypertensive effect and increased risk of renal dysfunction.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **CYP2C9 inhibitors (e.g., fluconazole):** May increase diclofenac levels.
## Monitoring
* **Renal function:** Baseline and periodically, especially in patients with risk factors for renal impairment.
* **Hepatic function:** Baseline and periodically, especially in patients with pre-existing liver disease.
* **Blood pressure:** Monitor for increased blood pressure.
* **Signs and symptoms of GI bleeding:** Especially in patients at high risk.
* **Signs and symptoms of cardiovascular events.**
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Administer with food or milk to reduce gastrointestinal upset.
* Extended-release formulations should not be crushed or chewed.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI bleeding.
* Be aware of the increased risk of cardiovascular events and GI bleeding associated with NSAID use.
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*This information is intended for healthcare professionals and does not substitute for professional medical advice. Always verify current prescribing information and consult with a qualified healthcare provider before making any treatment decisions.*
