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# Diclofenac (Oral)
## Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Rheumatoid arthritis
* Osteoarthritis
* Ankylosing spondylitis
* Pain (mild to moderate)
* Acute gouty arthritis
* Primary dysmenorrhea
## Adult Dosing
* **Rheumatoid Arthritis, Osteoarthritis, Ankylosing Spondylitis:** 150-200 mg per day in 2-3 divided doses.
* **Pain, Primary Dysmenorrhea:** Initial dose 50 mg, then 50 mg every 8 hours as needed. Alternatively, 100 mg initially, followed by 50 mg every 8 hours as needed. Maximum daily dose typically 150 mg.
* **Acute Gouty Arthritis:** 50 mg three times daily for 3 days.
## Pediatric Dosing
Dosing in pediatric patients is not well-established for most indications. Diclofenac oral formulations are generally not recommended for children under 12 years of age, except in specific cases like juvenile rheumatoid arthritis under specialist guidance.
## Dose Adjustments
* **Renal Impairment:** Use with caution. No specific dose reduction guidelines exist, but NSAIDs can worsen renal function.
* **Hepatic Impairment:** Use with caution. May require dose reduction in patients with mild to moderate hepatic impairment. Avoid in severe hepatic impairment.
## Contraindications
* Known hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of bronchospasm, asthma, rhinitis, or urticaria following aspirin or NSAID administration.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Active gastrointestinal bleeding or perforation.
* Inflammatory bowel disease (active).
* Congestive heart failure (established).
* Third trimester of pregnancy.
## Adverse Effects
* **Common:** Dyspepsia, nausea, abdominal pain, diarrhea, headache, dizziness.
* **Serious:** Gastrointestinal bleeding/perforation/ulceration, myocardial infarction, stroke, hypertension, renal failure, hepatotoxicity, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **ACE Inhibitors, ARBs, Beta-blockers:** Reduced antihypertensive effect, increased risk of renal dysfunction.
* **Corticosteroids:** Increased risk of GI bleeding.
* **Diuretics:** Reduced diuretic effect, increased risk of renal dysfunction.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **Warfarin/Anticoagulants:** Increased risk of bleeding.
## Monitoring
* **Before starting and periodically:** Blood pressure, renal function (serum creatinine, BUN), liver function (AST, ALT).
* **Patients with cardiovascular risk factors:** Monitor for signs of myocardial infarction or stroke.
* **Patients at risk for GI bleeding:** Monitor for signs and symptoms of GI bleeding.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Administer with food or milk to reduce gastrointestinal upset.
* Avoid concomitant use with other NSAIDs.
* Be aware of the increased risk of cardiovascular events and gastrointestinal bleeding, especially in elderly patients or those with pre-existing risk factors.
* Consider gastroprotection (e.g., proton pump inhibitor) for patients at high risk of GI events.
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**Disclaimer:** This information is intended for clinical use and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant guidelines for complete and up-to-date details.
