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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Rheumatoid arthritis
* Osteoarthritis
* Ankylosing spondylitis
* Acute pain
* Dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150-200 mg per day, divided into 3-4 doses. Maximum dose: 200 mg/day.
* **Acute Pain, Dysmenorrhea:** Initial dose 50 mg three times daily as needed. Alternatively, 50 mg initially followed by 50 mg doses every 8 hours as needed. Maximum dose: 200 mg/day.
## Pediatric Dosing
* Limited data. Some sources suggest 1-3 mg/kg/day in divided doses for juvenile rheumatoid arthritis, not to exceed adult doses.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Start at the lower end of the dosing range.
* **Renal Impairment:** Use with caution. 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.
* Known history of GI bleeding or perforation related to prior NSAID use.
* Active peptic ulceration or GI bleeding.
* Severe heart failure.
* Moderate to severe renal or hepatic impairment.
## Adverse Effects
* **Common:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, headache, dizziness, rash.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), GI bleeding, ulceration, perforation, renal toxicity, hepatic toxicity, hypersensitivity reactions, bronchospasm, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI bleeding and ulceration.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, Beta-blockers:** May reduce antihypertensive effect and increase risk of renal dysfunction.
* **Diuretics:** May reduce diuretic effect and increase risk of renal toxicity.
* **Lithium, Methotrexate:** Diclofenac can increase serum levels.
* **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac exposure.
## Monitoring
* Signs and symptoms of GI bleeding (melena, hematemesis).
* Renal function (BUN, creatinine), especially in patients with risk factors.
* Liver function tests (ALT, AST), especially with chronic use or history of liver disease.
* Blood pressure.
* Signs and symptoms of cardiovascular events.
## Clinical Pearls
* Administer with food or milk to minimize GI upset.
* Lowest effective dose for the shortest duration should be used.
* Risk of cardiovascular events and GI bleeding increases with dose and duration of use.
* Consider gastroprotective agents (e.g., PPIs) for patients at high risk of GI complications.
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*Disclaimer: This information is intended for healthcare professionals and should not be considered a substitute for professional medical advice. Always verify current prescribing information with official drug compendia or the manufacturer's product information before making any clinical decisions.*
