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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for its analgesic and anti-inflammatory properties.
## Primary Indications
* Pain associated with osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Mild to moderate pain
* Dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg daily, divided into 2 or 3 doses. A starting dose of 50 mg two or three times daily is common.
* **Pain, Dysmenorrhea:** 50 mg three times daily as needed.
* **Maximum Daily Dose:** Generally, do not exceed 200 mg/day. However, some indications may allow up to 225 mg/day under strict medical supervision.
## Pediatric Dosing
Dosing in pediatric patients is not well-established for oral diclofenac. Safety and efficacy have not been determined.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Dose reduction may be necessary, particularly in patients with cirrhosis. Specific guidelines for dose reduction are lacking; monitor for adverse effects closely.
* **Renal Impairment:** Use with caution. Not generally recommended in severe renal impairment. If used, monitor renal function closely.
## 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 peptic ulceration or gastrointestinal (GI) bleeding
* Inflammatory bowel disease (IBD) (e.g., Crohn's disease, ulcerative colitis)
## Adverse Effects
* **Common:** GI upset (nausea, vomiting, diarrhea, abdominal pain), dyspepsia, elevated liver enzymes, headache, dizziness, rash.
* **Serious:** GI bleeding, ulceration, perforation; cardiovascular thrombotic events (MI, stroke); renal papillary necrosis and other renal injury; hepatic failure; hypersensitivity reactions (including anaphylaxis); exacerbation of asthma; fluid retention and edema; hypertension.
## 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, Angiotensin Receptor Blockers (ARBs), Diuretics:** Increased risk of renal impairment; NSAIDs may reduce antihypertensive efficacy.
* **Lithium:** NSAIDs can decrease renal clearance of lithium, leading to increased serum lithium levels.
* **Methotrexate:** NSAIDs can increase methotrexate toxicity.
* **Selective Serotonin Reuptake Inhibitors (SSRIs):** Increased risk of GI bleeding.
* **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac plasma concentrations.
## Monitoring
* **GI:** Signs and symptoms of GI bleeding (e.g., melena, hematemesis, abdominal pain).
* **Renal:** Baseline and periodic renal function tests (serum creatinine, BUN), especially in patients with risk factors for renal impairment.
* **Hepatic:** Baseline and periodic liver function tests (ALT, AST), especially in patients with pre-existing liver disease or receiving long-term therapy.
* **Cardiovascular:** Monitor for signs of cardiovascular events.
* **Blood Pressure:** Monitor blood pressure, especially in patients with hypertension.
## Clinical Pearls
* Administer with food or milk to minimize GI upset.
* Lowest effective dose for the shortest duration necessary should be used to minimize risks.
* Consider GI protective agents (e.g., PPIs, misoprostol) for patients at high risk of GI complications.
* Patients with a history of NSAID-induced GI toxicity or risk factors for GI complications should be carefully assessed.
* NSAIDs, including diclofenac, carry a risk of cardiovascular events. Use cautiously in patients with cardiovascular disease or risk factors.
* NSAIDs can cause interstitial nephritis and renal papillary necrosis. Renal function should be monitored.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant literature for complete details, as drug information can change. Verify current prescribing information before making clinical decisions.
