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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Pain and inflammation associated with osteoarthritis
* Pain and inflammation associated with rheumatoid arthritis
* Pain and inflammation associated with ankylosing spondylitis
* Acute pain
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg per day in divided doses. Initial dose typically 50 mg three times daily or 75 mg twice daily. Maximum dose: 200 mg/day.
* **Acute Pain:** 50 mg every 8 hours as needed. Do not exceed 150 mg/day.
* **Delayed-Release Tablets:** Typically 50 mg to 100 mg once daily at the start of pain, with additional doses as needed, not to exceed 150 mg/day.
## Pediatric Dosing
The use of oral diclofenac in pediatric patients is generally not recommended due to lack of established safety and efficacy data for most indications and age groups. Dosing may be established by local protocol for specific indications in older children if deemed appropriate by a clinician.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate impairment may not require dose adjustment, but monitor closely. Avoid use in severe hepatic impairment.
* **Renal Impairment:** Use with caution. No specific dose adjustment is recommended for mild to moderate renal impairment, but monitor renal function closely. Avoid in severe renal impairment.
* **Elderly:** Increased risk of gastrointestinal, cardiovascular, and renal adverse effects. Consider lower doses and monitor closely.
## 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 ulceration or bleeding.
* Inflammatory bowel disease (active).
## Adverse Effects
Common:
* Gastrointestinal upset (nausea, vomiting, diarrhea, constipation, abdominal pain)
* Headache
* Dizziness
* Rash
Serious:
* Serious cardiovascular thrombotic events (myocardial infarction, stroke)
* Gastrointestinal bleeding, ulceration, and perforation
* Hepatotoxicity
* Renal toxicity (acute kidney injury)
* Fluid retention and edema
* Hypertension
* Hypersensitivity reactions
## Key Drug Interactions
* **ACE Inhibitors/ARBs:** Increased risk of renal impairment.
* **Anticoagulants (e.g., warfarin) and Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of gastrointestinal bleeding.
* **Diuretics:** Reduced efficacy and increased risk of renal toxicity.
* **Lithium:** Increased lithium levels and risk of toxicity.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **SSRIs/SNRIs:** Increased risk of gastrointestinal bleeding.
## Monitoring
* **Gastrointestinal:** Monitor for signs and symptoms of GI bleeding or ulceration.
* **Cardiovascular:** Monitor blood pressure and for signs of cardiovascular events, especially in patients with risk factors.
* **Renal:** Monitor renal function (BUN, creatinine) periodically, especially in patients with pre-existing renal disease or those at risk.
* **Hepatic:** Monitor liver function tests (AST, ALT) periodically, especially in patients with liver disease or those on long-term therapy.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Administer with food or milk to reduce gastrointestinal upset.
* Consider gastroprotective agents (e.g., PPIs) for patients at increased risk of GI complications.
* Avoid concomitant use with other NSAIDs.
* Caution in patients with heart failure, hypertension, or edema.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making treatment decisions. Dosing and recommendations may vary based on individual patient factors and local protocols.*
