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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, swelling, and inflammation. It works by inhibiting cyclooxygenase (COX) enzymes, thereby reducing prostaglandin synthesis.
## Primary Indications
* Pain and inflammation associated with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis.
* Mild to moderate pain.
* Primary dysmenorrhea.
## Adult Dosing
* **Osteoarthritis:** 25 mg PO TID or 50 mg PO BID. Maximum 150 mg/day.
* **Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg PO TID or 75 mg PO BID. Maximum 225 mg/day.
* **Mild to moderate pain, Primary dysmenorrhea:** 50 mg PO TID. Maximum 150 mg/day.
* Extended-release formulations and topical forms exist with different dosing schedules. Always refer to specific product labeling.
## Pediatric Dosing
* **Rheumatoid Arthritis:** 1-12 years: 2-3 mg/kg/day PO divided into 2-3 doses. Maximum 100 mg/day.
* **Pain, Dysmenorrhea:** Not typically recommended for children under 14 years for these indications, consult specialist literature.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Reduce dose in mild to moderate impairment. Avoid in severe impairment.
* **Renal Impairment:** Use with caution. Monitor renal function. Dose reduction may be considered in severe 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.
* Active gastrointestinal bleeding, ulceration, or perforation.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, ulceration, bleeding, perforation.
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, hypertension.
* **Renal:** Renal insufficiency, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Dermatologic:** Rash, pruritus.
* **Other:** Headache, dizziness, edema, tinnitus.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, diuretics:** Reduced antihypertensive effect, increased risk of renal impairment.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate toxicity.
## Monitoring
* Renal function (BUN, creatinine).
* Liver function tests (LFTs).
* Hemoglobin and hematocrit for signs of GI bleeding.
* Blood pressure.
* Signs and symptoms of cardiovascular events.
* Signs and symptoms of GI bleeding or ulceration.
## Clinical Pearls
* Administer with food or milk to minimize GI upset.
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotective agents (e.g., PPIs) in patients with increased risk of GI complications.
* Caution in elderly patients and those with pre-existing cardiovascular, renal, or hepatic disease.
* Monitor closely for signs of serious cardiovascular and gastrointestinal events, especially with prolonged use or in high-risk individuals.
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**Disclaimer:** This information is intended for healthcare professionals and does not replace the need to consult current prescribing information, institutional protocols, and clinical judgment. Always verify drug information with authoritative sources before use.
