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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, tenderness, swelling, and stiffness associated with osteoarthritis and rheumatoid arthritis. It works by inhibiting prostaglandin synthesis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain (mild to moderate)
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally three times daily, or 75 mg orally twice daily. Maximum dose: 225 mg/day.
* **Pain:** 50 mg orally every 8 hours as needed. Maximum dose: 150 mg/day.
* **Primary Dysmenorrhea:** 50 mg orally three times daily as needed. Maximum dose: 150 mg/day.
*Note: Delayed-release or enteric-coated formulations typically start at 25 mg four times daily, or 50 mg twice daily, with titration up to 75 mg four times daily or 100 mg twice daily. Maximum dose: 200 mg/day.*
## Pediatric Dosing
Dosing in pediatric patients is not well-established and should be determined by a specialist based on the specific condition and patient factors.
## Dose Adjustments
No specific dose adjustments are typically required for renal or hepatic impairment, but caution is advised. Consider the lowest effective dose and shortest duration of treatment, especially in patients with pre-existing renal or hepatic disease.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Last trimester of pregnancy.
## Adverse Effects
Common adverse effects include gastrointestinal upset, nausea, dyspepsia, abdominal pain, diarrhea, constipation, headache, dizziness, and rash. Serious adverse effects can include gastrointestinal bleeding, ulceration, perforation, cardiovascular thrombotic events (MI, stroke), renal toxicity, hepatic toxicity, and hypersensitivity reactions.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of gastrointestinal ulceration and bleeding.
* **SSRIs and SNRIs:** Increased risk of bleeding, particularly gastrointestinal bleeding.
* **Other NSAIDs and Aspirin:** Increased risk of adverse effects, especially gastrointestinal bleeding.
* **ACE Inhibitors, ARBs, Beta-Blockers:** May reduce antihypertensive efficacy and increase risk of renal impairment.
* **Diuretics:** May reduce diuretic efficacy and increase risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
## Monitoring
* Monitor for signs and symptoms of gastrointestinal bleeding (e.g., melena, hematemesis).
* Monitor blood pressure, especially in patients with hypertension.
* Monitor renal function (serum creatinine, BUN) and liver function (ALT, AST) periodically, particularly in patients with pre-existing impairment or those on long-term therapy.
* Assess for cardiovascular risk factors and monitor for signs of cardiovascular events.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Administer with food or milk to reduce gastrointestinal upset.
* Enteric-coated or delayed-release formulations may be preferred to reduce gastric irritation.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for gastrointestinal complications.
* Be aware of the increased risk of cardiovascular events and gastrointestinal bleeding with NSAID use.
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*This information is intended for clinical decision-making and does not replace the need to consult the official prescribing information and relevant clinical guidelines.*
