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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Pain relief (mild to moderate)
* Inflammation associated with conditions such as osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150-200 mg per day in 3-4 divided doses. Maximum daily dose is 200 mg.
* **Pain (Acute):** 25 mg every 6-8 hours as needed. Or, a single dose of 50 mg followed by 25 mg every 6-8 hours as needed. Do not exceed 75 mg on the first day, and 150 mg on subsequent days.
## Pediatric Dosing
The use of oral diclofenac in pediatric patients is generally not recommended due to insufficient data for efficacy and safety.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Starting doses should be lower. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function. Avoid in severe renal impairment.
* **Elderly:** Increased risk of adverse effects. Consider lower doses.
## 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
* **Common:** Gastrointestinal upset, nausea, abdominal pain, diarrhea, constipation, dyspepsia, elevated liver enzymes.
* **Serious:** Cardiovascular thrombotic events (myocardial infarction, stroke), gastrointestinal bleeding, ulceration, perforation, renal toxicity, hepatic failure, severe skin reactions (e.g., Stevens-Johnson syndrome).
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **ACE inhibitors, ARBs, Diuretics:** May reduce antihypertensive efficacy and increase risk of renal toxicity.
* **Lithium, Methotrexate:** Diclofenac may increase serum concentrations of these drugs.
* **Other NSAIDs (including aspirin):** Increased risk of adverse effects.
## Monitoring
* **Renal function:** Serum creatinine, BUN, particularly in patients with pre-existing renal disease or those at risk.
* **Hepatic function:** Liver enzymes (AST, ALT), especially with long-term use or in patients with liver disease.
* **Gastrointestinal symptoms:** Monitor for signs and symptoms of bleeding or ulceration.
* **Blood pressure:** Monitor for potential increases.
* **Signs of cardiovascular events:** Chest pain, shortness of breath, weakness, slurring of speech.
## Clinical Pearls
* Administer with food or milk to minimize gastrointestinal upset.
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
* Black Box Warning regarding cardiovascular and GI risks necessitates careful patient selection and counseling.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols for definitive guidance.*
