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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits prostaglandin synthesis. It is used for its analgesic, anti-inflammatory, and antipyretic properties.
## Primary Indications
* Pain relief (mild to moderate)
* Inflammation associated with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, gout flares, and other inflammatory conditions
* Primary dysmenorrhea
## Adult Dosing
* **Pain/Inflammation:**
* Immediate-release (IR): 25 mg three times daily or 50 mg twice daily. Maximum dose: 200 mg/day.
* Delayed-release (DR): 25 mg three to four times daily or 50 mg twice daily. Maximum dose: 200 mg/day.
* Extended-release (ER): 75 mg once or twice daily, or 100 mg once daily. Maximum dose: 100 mg/day.
* **Primary Dysmenorrhea:**
* IR: 50 mg three times daily as needed. Initiate at the first sign of pain. Maximum dose: 200 mg/day.
Dosing for specific conditions (e.g., gout, rheumatoid arthritis) may vary and should follow established guidelines or local protocols.
## Pediatric Dosing
* **Pain/Inflammation:**
* Children 2 to 12 years: 1 mg/kg/day divided into 3-4 doses. Maximum dose: 3 mg/kg/day or 200 mg/day, whichever is less.
* **Note:** Dosing for children should be carefully calculated and monitored. Not all formulations are approved for pediatric use.
## Dose Adjustments
* **Renal Impairment:** Use with caution. No specific dose adjustment is usually recommended for mild to moderate impairment, but monitor renal function closely. Contraindicated in severe renal impairment.
* **Hepatic Impairment:** Use with caution. No specific dose adjustment is usually recommended for mild to moderate impairment, but monitor liver function closely. Contraindicated in severe hepatic impairment.
* **Elderly:** Consider lower doses and increased frequency of monitoring due to increased risk of adverse events.
## 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.
* History of GI bleeding or perforation related to previous NSAID use.
* Active peptic ulceration or bleeding.
* Inflammatory bowel disease (IBD).
* Congestive heart failure (CHF), established ischemic heart disease, peripheral arterial disease.
* Third trimester of pregnancy.
* Severe renal or hepatic impairment.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, constipation, dyspepsia, abdominal pain, dizziness, headache, rash, edema.
* **Serious:**
* Cardiovascular: Myocardial infarction, stroke, hypertension, fluid retention.
* Gastrointestinal: GI bleeding, ulceration, perforation.
* Hepatic: Hepatotoxicity (rare but severe).
* Renal: Acute kidney injury, interstitial nephritis.
* Hypersensitivity reactions, including anaphylaxis.
* Skin reactions: Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, direct oral anticoagulants):** Increased risk of bleeding.
* **Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, Beta-blockers:** NSAIDs can reduce the antihypertensive effect and increase the risk of renal impairment.
* **Diuretics:** NSAIDs can reduce diuretic efficacy and increase the risk of nephrotoxicity.
* **Lithium:** Increased serum lithium levels and risk of toxicity.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **Cyclosporine/Tacrolimus:** Increased risk of nephrotoxicity.
## Monitoring
* **GI:** Monitor for signs and symptoms of GI bleeding (e.g., melena, hematemesis) and ulceration.
* **Cardiovascular:** Monitor blood pressure and for signs of fluid retention/edema. Assess cardiovascular risk factors.
* **Renal:** Monitor renal function (serum creatinine, BUN) especially in patients with pre-existing renal disease or risk factors.
* **Hepatic:** Monitor liver function tests (ALT, AST) especially in patients with pre-existing liver disease or those on long-term therapy.
* **Electrolytes:** Monitor if concerned about fluid and electrolyte balance.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize the risk of adverse events.
* Consider gastroprotection (e.g., PPI) in patients with increased GI risk factors.
* Educate patients on the signs and symptoms of serious adverse events (GI bleeding, cardiovascular events, liver/kidney problems).
* Diclofenac can mask signs of infection.
* Avoid concurrent use with other NSAIDs.
* Ensure adequate hydration.
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*This information is intended for healthcare professionals. Always consult the official prescribing information and current clinical guidelines for complete details and to ensure patient safety. Verify current prescribing information before making treatment decisions.*
