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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, swelling, and inflammation.
## Primary Indications
* Pain and inflammation associated with osteoarthritis
* Pain and inflammation associated with rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg daily, divided into 2 or 3 doses. Doses typically range from 50 mg twice daily to 75 mg twice daily.
* **Acute Pain:** Initial dose of 50 mg, followed by 50 mg every 8 hours as needed. Maximum daily dose for acute pain is 150 mg.
* **Maximum Daily Dose:** 200 mg/day for chronic conditions.
## Pediatric Dosing
* **Rheumatoid Arthritis:** 1 mg/kg/day to 3 mg/kg/day divided into 2 or 3 doses. The maximum daily dose should not exceed 200 mg. (Generally not recommended for children under 1 year of age).
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. No specific dose adjustment is typically recommended for mild to moderate impairment, but monitor closely. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. No specific dose adjustment is typically recommended for mild to moderate impairment, but monitor closely. Avoid in severe renal impairment.
* **Elderly:** Increased risk of adverse effects, particularly gastrointestinal bleeding and renal events. Consider using the lowest effective dose for the shortest duration.
## 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.
* Inflammatory bowel disease (active).
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, dyspepsia, abdominal pain, headache, dizziness, elevated liver enzymes.
* **Serious:**
* Cardiovascular thrombotic events (MI, stroke)
* Gastrointestinal bleeding, ulceration, perforation
* Hepatotoxicity (including liver failure)
* Renal toxicity (including acute kidney injury)
* Fluid retention and edema
* Serious skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis)
* Anaphylactic reactions
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, heparin, DOACs):** Increased risk of bleeding.
* **Aspirin (low-dose):** May reduce the cardioprotective effect of aspirin.
* **Corticosteroids:** Increased risk of gastrointestinal ulceration and bleeding.
* **Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):** Increased risk of bleeding.
* **Diuretics, ACE inhibitors, Angiotensin II Receptor Blockers (ARBs):** Reduced antihypertensive effect and increased risk of renal impairment.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **Cyclosporine, Tacrolimus:** Increased risk of nephrotoxicity.
## Monitoring
* **Gastrointestinal:** Monitor for signs and symptoms of bleeding (e.g., melena, hematemesis) and ulceration.
* **Cardiovascular:** Assess risk factors for cardiovascular disease.
* **Renal:** Monitor renal function (serum creatinine, BUN) especially in patients with pre-existing renal disease, dehydration, or those taking diuretics or ACE inhibitors.
* **Hepatic:** Monitor liver function tests (ALT, AST) periodically, especially in patients with chronic liver disease or those on long-term therapy. Discontinue if signs of liver injury occur.
* **Blood Pressure:** Monitor blood pressure, especially in patients with hypertension.
## Clinical Pearls
* Administer with food or milk to minimize gastric irritation.
* Use the lowest effective dose for the shortest duration necessary to reduce the risk of serious cardiovascular and gastrointestinal events.
* NSAIDs carry a risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke.
* NSAIDs can cause serious gastrointestinal bleeding, ulceration, and perforation.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
* Discontinue immediately if rash, visual disturbances, or signs of hypersensitivity occur.
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*Disclaimer: This information is intended for healthcare professionals and is not a substitute for clinical judgment. Always consult the most current prescribing information, patient-specific factors, and local guidelines before making any treatment decisions.*
