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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 associated with osteoarthritis
* Pain associated with rheumatoid arthritis
* Pain associated with ankylosing spondylitis
* Acute pain
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg daily, divided into 2 or 3 doses. Typical starting doses are 50 mg three times daily or 75 mg twice daily.
* **Acute Pain:** 50 mg every 8 hours as needed for pain. Do not exceed 150 mg in the first 24 hours.
* **Maximum Daily Dose:** 200 mg
## Pediatric Dosing
Dosing in pediatric patients is not well-established and should be based on patient weight and clinical judgment.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate hepatic impairment may not require dose adjustment, but patients should be monitored for adverse effects. Severe hepatic impairment is a contraindication.
* **Renal Impairment:** Use with caution. Mild to moderate renal impairment may not require dose adjustment, but patients should be monitored for adverse effects. Severe renal impairment is not an absolute contraindication but requires caution and close monitoring.
## 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
* Advanced renal disease
* Advanced hepatic disease
* Inflammatory bowel disease (active)
* History of gastrointestinal bleeding or perforation related to prior NSAID use
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, abdominal pain, nausea, vomiting, diarrhea, constipation, flatulence, gastrointestinal bleeding, ulceration, perforation.
* **Cardiovascular:** Increased risk of serious cardiovascular thrombotic events, myocardial infarction, stroke. Hypertension. Fluid retention, edema.
* **Renal:** Renal impairment, acute renal failure, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice, hepatic failure.
* **Dermatologic:** Rash, pruritus, urticaria, Stevens-Johnson syndrome, toxic epidermal necrolysis.
* **Other:** Headache, dizziness, tinnitus, hypersensitivity reactions.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Aspirin:** Increased risk of GI ulceration and bleeding. Concurrent use is generally not recommended.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Selective Serotonin Reuptake Inhibitors (SSRIs) / Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):** Increased risk of GI bleeding.
* **Diuretics, ACE inhibitors, Angiotensin II Receptor Blockers (ARBs):** May decrease antihypertensive effect and increase risk of renal impairment.
* **Lithium:** Increased lithium levels and toxicity.
* **Methotrexate:** Increased methotrexate levels and toxicity.
* **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac levels.
## Monitoring
* **Renal function:** Serum creatinine, BUN, urine output.
* **Hepatic function:** Liver function tests (ALT, AST, bilirubin).
* **Gastrointestinal symptoms:** Assess for signs of bleeding or ulceration.
* **Cardiovascular risk factors:** Blood pressure, signs of fluid retention.
* **Hemoglobin/Hematocrit:** Especially with prolonged use or if GI bleeding is suspected.
## Clinical Pearls
* The lowest effective dose should be used for the shortest duration necessary to minimize risks.
* Consider co-prescription of a proton pump inhibitor (PPI) for patients at increased risk of gastrointestinal events.
* NSAIDs can mask signs and symptoms of infection.
* Avoid in patients with NSAID-exacerbated respiratory disease.
* Extended-release formulations have different dosing and administration instructions.
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*This information is intended for healthcare professionals. Please consult the official prescribing information and relevant clinical guidelines for complete details and to verify current recommendations before making any clinical decisions.*
