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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain and inflammation. It works by inhibiting cyclooxygenase (COX) enzymes, thereby reducing prostaglandin synthesis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute musculoskeletal disorders
* Low back pain
* Menstrual pain (dysmenorrhea)
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** Typically 150 mg daily, divided into 2 or 3 doses. Maximum dose: 225 mg daily. Extended-release formulations: 100 mg once daily.
* **Acute Pain, Dysmenorrhea:** Initial dose 50 mg three times daily, or 100 mg initially followed by 50 mg every 8 hours as needed. Maximum dose: 200 mg daily.
* **Low Back Pain:** Initial dose 50 mg three times daily or 75 mg twice daily. Maximum dose: 225 mg daily.
## Pediatric Dosing
Dosing in pediatric patients is not well-established for all indications. Specific recommendations may vary by age and indication. For example, for juvenile idiopathic arthritis, a common regimen is 2-3 mg/kg/day divided into 2-3 doses, not to exceed the adult maximum. Always consult specific pediatric guidelines.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate impairment may require dose reduction. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function, especially in patients with pre-existing renal disease or those at risk for renal complications. Dose reduction may be considered.
## 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 bleeding or ulceration.
* Severe heart failure.
* Third trimester of pregnancy.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, flatulence, peptic ulceration, GI bleeding.
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, hypertension, fluid retention, edema.
* **Renal:** Renal insufficiency, acute renal failure.
* **Hepatic:** Elevated liver enzymes, hepatitis.
* **Hematologic:** Anemia, bruising, prolonged bleeding time.
* **Dermatologic:** Rash, pruritus.
* **Other:** Headache, dizziness, tinnitus, hypersensitivity reactions.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Other NSAIDs (including aspirin):** Increased risk of adverse effects, particularly GI bleeding.
* **ACE Inhibitors, ARBs, Beta-blockers:** Reduced antihypertensive efficacy; increased risk of renal dysfunction.
* **Diuretics:** Reduced diuretic efficacy; increased risk of renal dysfunction.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **SSRIs:** Increased risk of GI bleeding.
## Monitoring
* **GI Bleeding:** Monitor for signs and symptoms (e.g., melena, hematemesis, abdominal pain).
* **Cardiovascular Risk:** Monitor blood pressure and for signs of fluid retention. Counsel patients on cardiovascular risks.
* **Renal Function:** Monitor serum creatinine and BUN, especially in at-risk patients.
* **Hepatic Function:** Monitor liver enzymes, especially with long-term use or in patients with pre-existing liver disease.
* **Blood Pressure:** Regular monitoring is recommended, particularly when initiating therapy.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider co-prescription of a proton pump inhibitor (PPI) or misoprostol for patients at high risk of GI complications.
* Caution in elderly patients and those with a history of GI bleeding, renal impairment, heart failure, or hypertension.
* NSAIDs can mask signs of infection.
* Discontinue immediately if signs of serious cardiovascular events or severe hypersensitivity reactions occur.
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**Disclaimer:** This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for complete details and to ensure patient safety.
