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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, swelling, and inflammation.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain associated with musculoskeletal disorders
* Acute pain
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg per day, divided into 2 to 4 doses. Initial dose typically 50 mg three times daily or 75 mg twice daily.
* **Acute Pain:** Initial dose 50 mg, followed by 50 mg every 8 hours as needed. Total daily dose should not exceed 150 mg for the first day.
* **Other Musculoskeletal Conditions:** 100 mg to 150 mg per day, divided into 3 to 4 doses.
Maximum daily dose: 200 mg.
## Pediatric Dosing
Diclofenac is not generally recommended for use in pediatric patients due to safety and efficacy concerns. Limited data exists for specific indications and age groups, and dosing is highly individualized and should be determined by a specialist.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Start at the lower end of the dosage range. Monitor liver function closely.
* **Renal Impairment:** Use with caution. Patients with mild to moderate renal impairment may not require dose adjustments, but close monitoring is advised. Avoid 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.
* Active gastrointestinal bleeding or ulceration.
* Inflammatory bowel disease.
* Severe heart failure.
* Severe hepatic impairment.
* Severe renal impairment.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, vomiting, abdominal pain, diarrhea, constipation, elevated liver enzymes, peptic ulceration, GI bleeding/perforation.
* **Cardiovascular:** Hypertension, edema, increased risk of myocardial infarction and stroke (especially with long-term use or in patients with risk factors).
* **Renal:** Renal insufficiency, interstitial nephritis.
* **Dermatologic:** Rash, pruritus.
* **Hematologic:** Anemia, bruising.
* **Other:** Dizziness, headache, tinnitus, photosensitivity.
## 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 ARBs:** May diminish antihypertensive effect and increase risk of renal impairment.
* **Diuretics:** May diminish diuretic effect and increase risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **Other NSAIDs:** Increased risk of adverse effects, particularly GI.
## Monitoring
* **Baseline and periodic:** Liver function tests (ALT, AST), renal function (creatinine, BUN), complete blood count (CBC).
* **During treatment:** Blood pressure, signs and symptoms of GI bleeding, fluid retention.
## Clinical Pearls
* Administer with food or milk to minimize GI upset.
* The lowest effective dose should be used for the shortest duration necessary to minimize the risk of cardiovascular and GI events.
* Consider gastroprotective agents (e.g., PPIs) for patients at high risk of GI complications.
* Monitor patients closely for signs of cardiovascular events, particularly those with pre-existing cardiovascular disease.
* Avoid concurrent use with other NSAIDs.
**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and local protocols for definitive guidance.
