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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis. It is available in oral, topical, and intravenous formulations.
## Primary Indications
* Pain relief (e.g., musculoskeletal pain, postoperative pain)
* Inflammation associated with osteoarthritis and rheumatoid arthritis
## Adult Dosing
* **Oral (Immediate-release):** 25 mg to 50 mg two to three times daily. Maximum daily dose: 150 mg.
* **Oral (Delayed-release/Enteric-coated):** 75 mg two times daily or 100 mg once daily. Maximum daily dose: 150 mg.
* **Oral (Extended-release):** 100 mg once daily. Maximum daily dose: 100 mg.
* **Topical:** Apply to affected area one to four times daily. Specific dosing varies by product (e.g., gel, patch).
* **Intravenous:** Typically 75 mg every 8 hours as needed, or a continuous infusion. Often used for postoperative pain. Consult specific institutional protocols.
## Pediatric Dosing
* **Oral (Delayed-release):** Children 1 to 12 years: 1 mg/kg/day divided into 2 to 4 doses. Maximum daily dose: 3 mg/kg/day or 75 mg/day, whichever is less.
* **Oral (Extended-release):** Not generally recommended for pediatric use.
* **Topical/Intravenous:** Limited data; use in pediatric populations should be guided by specific product information and expert consultation.
## Dose Adjustments
* **Renal Impairment:** Use with caution; dosage reduction may be necessary. Monitor renal function.
* **Hepatic Impairment:** Use with caution; dosage reduction may be necessary. Monitor liver function.
* **Elderly:** Increased risk of adverse effects; consider lower doses and shorter duration of therapy.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active gastrointestinal (GI) bleeding or ulceration.
* History of GI bleeding or perforation related to previous NSAID use.
* Severe heart failure, renal impairment, or hepatic impairment.
* Third trimester of pregnancy.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
## Adverse Effects
Common: GI upset (nausea, vomiting, diarrhea, constipation), abdominal pain, dyspepsia, headache, dizziness, rash.
Serious: Cardiovascular thrombotic events (MI, stroke), GI bleeding/perforation, renal failure, hepatic failure, hypersensitivity reactions, bronchospasm.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin) and Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **ACE Inhibitors and Angiotensin Receptor Blockers (ARBs):** May reduce antihypertensive effect and increase risk of renal dysfunction.
* **Diuretics:** May reduce diuretic effect and increase risk of renal dysfunction.
* **Lithium:** Increased lithium levels and toxicity.
* **Methotrexate:** Increased methotrexate toxicity.
* **SSRIs:** Increased risk of GI bleeding.
## Monitoring
* Renal function (serum creatinine, BUN)
* Liver function (AST, ALT)
* Complete blood count (CBC) for signs of anemia or bleeding
* Signs and symptoms of GI bleeding or ulceration
* Cardiovascular risk factors
* Blood pressure
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Consider gastroprotection (e.g., PPI) in patients at high risk for GI events.
* Topical formulations may offer a lower systemic absorption and reduced risk of GI adverse effects compared to oral formulations.
* IV diclofenac is generally reserved for short-term use.
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*Disclaimer: This information is intended for healthcare professionals. It is essential to consult the most current prescribing information, local institutional guidelines, and patient-specific factors before administering any medication.*
