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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation management. It works by inhibiting cyclooxygenase (COX) enzymes, thereby reducing prostaglandin synthesis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg daily, divided into 2 or 3 doses. Maximum daily dose is 200 mg.
* **Acute Pain:** Initial dose of 50 mg, followed by 50 mg every 8 hours as needed. Alternatively, 75 mg twice daily.
* **Primary Dysmenorrhea:** Initial dose of 50 mg, followed by 25 mg or 50 mg every 8 hours as needed. Alternatively, 100 mg initially, followed by 50 mg every 8 hours.
## Pediatric Dosing
Dosing for children is not well-established for diclofenac oral formulations. Consult specific pediatric guidelines or specialist recommendations.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Start at the lower end of the dosage range. Monitor liver function closely. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function. Avoid in severe renal impairment.
## 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 gastrointestinal bleeding or ulceration.
* Inflammatory bowel disease (active).
* Heart failure (NYHA Class II-IV).
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, flatulence, GI bleeding, ulceration, perforation.
* **Cardiovascular:** Increased risk of myocardial infarction and stroke, hypertension, edema.
* **Renal:** Acute kidney injury, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Hematologic:** Anemia, increased bleeding time.
* **Dermatologic:** Rash, pruritus.
* **Other:** Headache, dizziness, tinnitus, bronchospasm (especially in aspirin-sensitive asthmatics).
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Antiplatelet agents (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI toxicity.
* **ACE inhibitors, ARBs, Beta-blockers:** May reduce antihypertensive effect and increase risk of renal impairment.
* **Diuretics:** May reduce diuretic effect and increase risk of renal impairment.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **SSRIs:** Increased risk of GI bleeding.
## Monitoring
* **Baseline and periodic monitoring of:** Renal function (serum creatinine, BUN), liver function (AST, ALT), complete blood count (CBC) with differential, and electrolytes.
* **Monitor for signs and symptoms of:** GI bleeding (melena, hematemesis), cardiovascular events (chest pain, shortness of breath), hypersensitivity reactions, and fluid retention.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Administer with food or milk to minimize GI upset.
* Consider co-prescription of a proton pump inhibitor (PPI) or misoprostol for patients at increased risk of GI complications.
* Be aware of the increased cardiovascular and GI risks associated with NSAID use, especially in elderly patients or those with pre-existing risk factors.
* Avoid concomitant use with other NSAIDs or aspirin (unless for cardioprotection at low dose, with caution).
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**Disclaimer:** This information is for educational purposes only and does not substitute for professional medical advice. Always consult current prescribing information and your healthcare provider for accurate and up-to-date guidance.
