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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 management (e.g., acute pain, post-operative pain)
* Dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release: 150 mg to 200 mg daily, divided into 2 to 4 doses. Maximum: 200 mg/day.
* Delayed-release: 75 mg to 100 mg daily, divided into 2 doses. Maximum: 100 mg/day.
* Extended-release: 100 mg to 200 mg once daily. Maximum: 200 mg/day.
* **Pain Management, Dysmenorrhea:**
* Immediate-release: 50 mg three times daily.
* For acute pain, initial doses of 50 mg may be followed by 50 mg every 8 hours as needed.
* Maximum: 150 mg/day for rheumatoid arthritis, 200 mg/day for osteoarthritis or other indications.
## Pediatric Dosing
Dosing for children is not well-established for most oral formulations and depends on the specific indication and available product. Consult specific pediatric guidelines or product monographs.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. No specific dose adjustment, but monitor for adverse effects.
* **Renal Impairment:** Use with caution. No specific dose adjustment, but monitor for adverse effects, especially in severe renal impairment.
## Contraindications
* 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, abdominal pain, nausea, diarrhea, constipation, ulceration, bleeding, perforation.
* **Cardiovascular:** Increased risk of myocardial infarction and stroke. Hypertension.
* **Renal:** Renal papillary necrosis, interstitial nephritis, renal failure.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Dermatologic:** Rash, pruritus, Stevens-Johnson syndrome, toxic epidermal necrolysis.
* **Other:** Dizziness, headache, 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 bleeding.
* **Lithium:** Increased lithium levels and toxicity.
* **Methotrexate:** Increased methotrexate levels and toxicity.
* **ACE Inhibitors/ARBs/Diuretics:** Reduced antihypertensive effect, increased risk of renal impairment.
* **Other NSAIDs/Aspirin:** Increased risk of GI toxicity and other adverse effects.
## Monitoring
* **GI Bleeding/Perforation:** Monitor for signs and symptoms (e.g., melena, hematemesis, abdominal pain).
* **Cardiovascular Risk:** Monitor blood pressure. Advise patients on signs/symptoms of MI/stroke.
* **Renal Function:** Baseline and periodic renal function tests, especially in patients with risk factors.
* **Hepatic Function:** Baseline and periodic liver function tests, especially in patients with pre-existing liver disease.
* **Electrolytes:** Monitor if edema or other signs of fluid retention are present.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Administer with food or milk to reduce GI upset.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
* NSAIDs can mask signs of infection.
* Be aware of the increased risk of cardiovascular events with chronic NSAID use.
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**Disclaimer:** This information is intended for healthcare professionals. Always verify current prescribing information and consult with the patient's specific clinical situation before making treatment decisions.
