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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation.
## Primary Indications
* Pain associated with osteoarthritis
* Pain associated with rheumatoid arthritis
* Pain associated with ankylosing spondylitis
* Acute pain
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg per day, divided into 2 or 3 doses. Usual starting dose: 50 mg two or three times daily.
* **Acute Pain:** Initial dose: 50 mg, followed by 50 mg every 8 hours as needed. Do not exceed 200 mg in the first 24 hours.
* **Delayed-release formulations:** Typically 75 mg twice daily.
* **Extended-release formulations:** Typically 100 mg to 200 mg once daily.
The lowest effective dose should be used for the shortest duration necessary.
## Pediatric Dosing
Diclofenac is not generally recommended for use in pediatric patients for the approved indications due to lack of established efficacy and safety.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Consider a lower starting dose and monitor closely. Not recommended in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function. Not recommended in severe renal impairment.
* **Elderly:** Increased risk of adverse events, particularly gastrointestinal bleeding and cardiovascular events. Consider a lower starting 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.
## Adverse Effects
* **Common:** Abdominal pain, nausea, vomiting, diarrhea, dyspepsia, flatulence, constipation, rash, dizziness, headache.
* **Serious:**
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, and death.
* **Gastrointestinal:** Increased risk of serious GI bleeding, ulceration, and perforation.
* **Renal:** Renal papillary necrosis and other renal injury.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Hypersensitivity:** Anaphylactic reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI bleeding.
* **Diuretics:** Decreased diuretic effect, increased risk of renal toxicity.
* **Lithium:** Increased serum lithium levels and toxicity.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **Other NSAIDs:** Increased risk of adverse effects.
* **Selective Serotonin Reuptake Inhibitors (SSRIs):** Increased risk of GI bleeding.
* **Tacrolimus:** Increased risk of nephrotoxicity.
## Monitoring
* **Renal function:** Baseline and periodic monitoring, especially in patients with pre-existing renal disease or those at risk.
* **Hepatic function:** Baseline and periodic monitoring, especially in patients with liver disease or those at risk.
* **Blood pressure:** Monitor for potential increases.
* **Signs and symptoms of GI bleeding:** Black, tarry stools; hematemesis; abdominal pain.
* **Signs and symptoms of cardiovascular events:** Chest pain, shortness of breath, weakness, slurring of speech.
## Clinical Pearls
* Diclofenac carries a black box warning for increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke.
* It also carries a black box warning for serious gastrointestinal bleeding, ulceration, and perforation.
* The lowest effective dose should be used for the shortest duration necessary to minimize risks.
* Consider gastroprotective agents (e.g., proton pump inhibitors) in patients at high risk of GI complications.
* Avoid concurrent use with other NSAIDs.
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**Disclaimer:** This information is intended for educational purposes and does not substitute for professional medical advice. Always consult with a qualified healthcare provider to ensure the information is current and appropriate for your specific needs. Review the most recent prescribing information and consult relevant guidelines before making any clinical decisions.
