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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, inflammation, and stiffness.
## 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 to 3 doses.
* *Extended-release:* 100 mg once daily or 200 mg once daily.
* **Acute Pain:** 220 mg (often a delayed-release formulation) as a single dose.
* **Primary Dysmenorrhea:** 500 mg initially, followed by 250 mg every 8 hours as needed. Or 200 mg initially, followed by 100 mg to 200 mg every 8 hours as needed.
Maximum daily dose: 200 mg (for arthritis indications).
## Pediatric Dosing
Limited data for oral diclofenac in pediatrics. Dosing is not well-established and should be based on specific indications and physician guidance, often requiring specialist consultation.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. May require dose reduction.
* **Renal Impairment:** Use with caution. Monitor renal function closely. Data for dose adjustment is limited.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active peptic ulceration or bleeding.
* History of GI bleeding or perforation related to prior NSAID use.
* Severe heart failure.
* Last trimester of pregnancy.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, flatulence, peptic ulceration, GI bleeding, perforation.
* **Cardiovascular:** Increased risk of serious cardiovascular thrombotic events (MI, stroke), hypertension, edema.
* **Renal:** Renal insufficiency, acute kidney injury.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Other:** Headache, dizziness, rash, hypersensitivity reactions.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin), antiplatelets (e.g., aspirin, clopidogrel):** 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 impairment.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **CYP2C9 inhibitors (e.g., fluconazole):** May increase diclofenac plasma concentrations.
## Monitoring
* **Renal function:** Serum creatinine, BUN.
* **Hepatic function:** LFTs (ALT, AST).
* **Complete blood count (CBC):** For signs of anemia or GI bleeding.
* **Blood pressure.**
* **Signs and symptoms of GI bleeding or ulceration.**
## Clinical Pearls
* Lowest effective dose for the shortest duration necessary should be used to minimize GI and cardiovascular risks.
* Consider co-administration with a proton pump inhibitor (PPI) or misoprostol in patients at high risk for GI complications.
* NSAIDs can mask signs of infection.
* Discontinue at the first sign of rash or any sign of hypersensitivity or serious adverse reaction.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and clinical guidelines before making any treatment decisions.*
