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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation.
## Primary Indications
* Pain and inflammation associated with osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
* Management of mild to moderate pain.
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg orally per day, divided into 2 or 3 doses. Typically initiated at 50 mg three times daily or 75 mg twice daily.
* **Pain:** 400 mg orally per day, divided into 4 doses. Typically initiated at 50 mg three times daily.
## Pediatric Dosing
* Data on oral diclofenac in pediatrics is limited. Use is generally not recommended.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Dose reduction may be necessary in patients with mild to moderate hepatic impairment. Avoid use in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function closely. Avoid use in severe renal impairment.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of bronchospasm, 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
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, peptic ulceration, GI bleeding.
* **Cardiovascular:** Increased risk of myocardial infarction and stroke.
* **Renal:** Renal insufficiency, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis.
* **Dermatologic:** Rash, pruritus.
* **Other:** Dizziness, headache, tinnitus, edema.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Other NSAIDs/Aspirin:** Increased risk of GI adverse effects and reduced cardioprotective effects of low-dose aspirin.
* **ACE inhibitors, ARBs, diuretics:** Reduced antihypertensive efficacy and increased risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
## Monitoring
* **Renal function:** Serum creatinine, BUN, especially in patients with pre-existing renal disease or those at risk.
* **Hepatic function:** Liver enzymes (ALT, AST), especially with chronic use or in patients with liver disease.
* **Gastrointestinal symptoms:** Monitor for signs of bleeding or ulceration.
* **Blood pressure:** NSAIDs can increase blood pressure.
* **Signs and symptoms of cardiovascular events:** Chest pain, shortness of breath, weakness, slurring of speech.
## Clinical Pearls
* Diclofenac carries a boxed warning for increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke.
* The lowest effective dose for the shortest duration necessary should be used to minimize risks.
* Consider gastroprotection (e.g., PPI) in patients at high risk for GI complications.
* Patients with heart failure, hypertension, or edema should be monitored closely.
Please verify current prescribing information for the most up-to-date dosing, indications, contraindications, and safety information.
