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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation. It works by inhibiting cyclooxygenase (COX) enzymes, which reduces prostaglandin synthesis.
## Primary Indications
* Inflammatory conditions (e.g., rheumatoid arthritis, osteoarthritis)
* Acute pain
* Menstrual cramps (dysmenorrhea)
## Adult Dosing
* **Immediate-release:** 25 mg to 50 mg orally three to four times daily.
* **Delayed-release:** 25 mg to 75 mg orally two to three times daily.
* **Extended-release:** 75 mg to 100 mg orally once or twice daily.
* **Acute pain:** 50 mg every 8 hours for the first dose, then 50 mg every 6-8 hours as needed.
* **Dysmenorrhea:** 50 mg three times daily as needed, or 100 mg initially followed by 50 mg every 8 hours as needed.
**Maximum daily dose:** 225 mg (immediate-release) or 300 mg (delayed-release).
## Pediatric Dosing
* **Rheumatoid arthritis:** 2 mg/kg/day orally divided into two to four doses.
* **Maximum pediatric dose:** Not to exceed 75 mg/day.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. No specific dose reduction guidelines, but monitor liver function.
* **Renal Impairment:** Use with caution. May increase risk of renal toxicity.
## 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 gastrointestinal (GI) bleeding or perforation.
## Adverse Effects
* **Common:** Nausea, vomiting, dyspepsia, abdominal pain, diarrhea, constipation, headache, dizziness.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), GI bleeding, ulceration, perforation, renal failure, hepatotoxicity, hypersensitivity reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI bleeding and ulceration.
* **Selective Serotonin Reuptake Inhibitors (SSRIs) / Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):** Increased risk of bleeding.
* **Other NSAIDs/Aspirin:** Increased risk of GI toxicity and other adverse effects.
* **ACE inhibitors, Angiotensin II Receptor Blockers (ARBs):** Decreased antihypertensive effect, increased risk of renal impairment.
* **Diuretics:** Decreased diuretic effect, increased risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
## Monitoring
* Signs and symptoms of GI bleeding.
* Renal function (BUN, creatinine).
* Liver function tests (ALT, AST).
* Blood pressure.
* Signs of cardiovascular events.
## Clinical Pearls
* Lowest effective dose for shortest duration should be used to minimize risk of serious adverse effects.
* Administer with food or milk to reduce GI upset.
* Avoid concomitant use with other NSAIDs.
* Patients with pre-existing cardiovascular disease or risk factors should be monitored closely.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
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*This information is intended for healthcare professionals and should not be used as a substitute for professional medical advice. Always verify current prescribing information and consult with a qualified healthcare provider.*
