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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation management. It works by inhibiting cyclooxygenase (COX) enzymes, thereby reducing prostaglandin synthesis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Menstrual pain (dysmenorrhea)
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150-200 mg per day in 2-4 divided doses.
* Maximum daily dose: 200 mg.
* **Acute Pain:** 25 mg every 4-6 hours as needed.
* Maximum daily dose: 100 mg in the first 24 hours, then 75 mg per day thereafter.
* **Dysmenorrhea:** Initial dose 50 mg, then 25-50 mg every 6-8 hours as needed.
* Maximum daily dose: 200 mg.
Dosing is typically initiated at the lowest effective dose and for the shortest duration necessary.
## Pediatric Dosing
Diclofenac oral formulations are **not generally recommended** for children under 14 years of age due to lack of established dosing and safety data.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Consider a lower starting dose. Monitor for adverse effects.
* **Renal Impairment:** Use with caution. Monitor renal function closely. Avoid in severe renal impairment.
## Contraindications
* Known 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.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, GI bleeding, perforation, ulceration (risk increases with dose and duration).
* **Cardiovascular:** Increased risk of serious cardiovascular thrombotic events, myocardial infarction, stroke.
* **Renal:** Acute kidney injury, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Dermatologic:** Rash, pruritus.
* **Other:** Headache, dizziness, tinnitus, fluid retention, edema.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, DOACs):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Other NSAIDs (including aspirin):** Increased risk of adverse effects, particularly GI bleeding.
* **SSRIs and SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, Beta-blockers, Diuretics:** Reduced antihypertensive effect and increased risk of renal impairment.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
## Monitoring
* **GI symptoms:** Assess for signs of bleeding or ulceration.
* **Renal function:** Monitor serum creatinine and BUN, especially in patients with pre-existing renal disease or those at risk.
* **Liver function:** Monitor ALT, AST, especially with long-term use or in patients with liver disease.
* **Blood pressure:** Monitor for potential increases.
* **Cardiovascular risk factors:** Assess and manage.
## Clinical Pearls
* Administer with food or milk to minimize GI upset.
* Use the lowest effective dose for the shortest duration possible to minimize risks.
* Be aware of the black box warning regarding cardiovascular thrombotic events and GI bleeding.
* Consider concurrent gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
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**Disclaimer:** This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for definitive patient care decisions. Drug information can change rapidly.
