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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation management.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150-200 mg daily, divided into 2-3 doses. Maximum 200 mg/day.
* **Acute Pain:** 200 mg on the first day, then 100 mg daily thereafter, divided into 2-3 doses.
* **Primary Dysmenorrhea:** 100 mg on the first day, followed by 50 mg every 8 hours as needed. Maximum 150 mg/day on day 1, then 100 mg/day thereafter.
* **Delayed-release tablets:** Typically 50 mg two to three times daily, or 75 mg twice daily.
## Pediatric Dosing
Dosing is not well established for all indications.
* **Juvenile Idiopathic Arthritis:** 1-3 mg/kg/day divided into 2-3 doses. Maximum 200 mg/day.
## Dose Adjustments
* **Renal Impairment:** Use with caution. Dosage reduction may be considered in severe impairment, but specific guidelines are lacking. Monitor renal function.
* **Hepatic Impairment:** Use with caution. Initiate at the lower end of the dose range. Monitor liver function. Avoid in severe hepatic impairment.
## Contraindications
* Known 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.
* Active gastrointestinal (GI) bleeding or ulceration.
* Inflammatory bowel disease (active).
* Third trimester of pregnancy.
## Adverse Effects
* **Common:** Abdominal pain, nausea, dyspepsia, diarrhea, constipation, headache, dizziness.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), GI bleeding/perforation/ulceration, renal toxicity, hepatic injury, hypersensitivity reactions, Stevens-Johnson syndrome/toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, apixaban):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI bleeding/ulceration.
* **Other NSAIDs (including aspirin):** Increased risk of GI toxicity and additive effects.
* **ACE Inhibitors/ARBs:** Reduced antihypertensive effect, increased risk of renal impairment.
* **Diuretics:** Reduced diuretic efficacy, increased risk of renal impairment.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate toxicity.
## Monitoring
* Renal function (BUN, creatinine)
* Liver function tests (AST, ALT)
* Complete blood count (CBC)
* Signs and symptoms of GI bleeding
* Blood pressure
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Consider GI protective agents (e.g., PPIs) in patients at high risk for GI complications.
* Advise patients to report signs of GI bleeding (black, tarry stools; hematemesis) or cardiovascular events (chest pain, shortness of breath).
* Avoid concomitant use with other NSAIDs.
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*This information is intended for healthcare professionals. Please verify current prescribing information and local protocols before making clinical decisions.*
