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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Rheumatoid arthritis
* Osteoarthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Rheumatoid Arthritis, Osteoarthritis, Ankylosing Spondylitis:** 150 mg to 200 mg daily, divided into 2 to 4 doses.
* Extended-release formulation: 100 mg to 200 mg once daily.
* **Acute Pain:** 150 mg daily, divided into 3 doses. May use 50 mg every 8 hours for up to 7 days.
* **Primary Dysmenorrhea:** 50 mg three times daily as needed, or 100 mg once daily for up to 3 days.
Maximum daily dose: 200 mg.
## Pediatric Dosing
Dosing is not well-established for oral diclofenac in pediatric patients for most indications. Extended-release formulations are not recommended in children.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. No specific dose adjustment is recommended, but monitor for adverse effects.
* **Renal Impairment:** Use with caution. No specific dose adjustment is recommended, but monitor for adverse effects. NSAIDs can precipitate renal failure.
## 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 bleeding or perforation.
## Adverse Effects
* **Common:** Abdominal pain, nausea, vomiting, diarrhea, dyspepsia, headache, dizziness, rash.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), gastrointestinal perforation and bleeding, hepatotoxicity, renal toxicity, fluid retention and edema, hypertension, serious skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis).
## Key Drug Interactions
* **ACE Inhibitors & ARBs:** Decreased antihypertensive effect, increased risk of renal impairment.
* **Corticosteroids:** Increased risk of gastrointestinal bleeding.
* **Anticoagulants (e.g., Warfarin):** Increased risk of bleeding.
* **Other NSAIDs (including Aspirin):** Increased risk of adverse effects, particularly GI bleeding.
* **Diuretics:** Reduced diuretic and antihypertensive efficacy, increased risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **SSRIs:** Increased risk of gastrointestinal bleeding.
## Monitoring
* **Baseline and Periodic:** Liver function tests (ALT, AST), renal function (serum creatinine, BUN), complete blood count (CBC).
* **Ongoing:** Blood pressure, signs and symptoms of GI bleeding, signs of fluid retention or edema.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize the risk of serious cardiovascular and gastrointestinal events.
* Risk of serious cardiovascular events is increased with higher doses and longer duration of use.
* Risk of serious gastrointestinal bleeding, ulceration, and perforation increases with dose and duration, and in elderly patients.
* Concomitant use with alcohol may increase the risk of GI adverse effects.
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*Disclaimer: This information is for educational purposes and does not substitute for professional medical advice. Always consult the most current prescribing information and relevant guidelines before making any treatment decisions.*
