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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, swelling, and inflammation.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg per day, divided into 3 or 4 doses. Maximum recommended daily dose is 200 mg.
* **Acute Pain:** Initial dose of 50 mg, followed by 50 mg every 8 hours as needed. Do not exceed 150 mg per day.
* **Primary Dysmenorrhea:** Initial dose of 50 mg, followed by 50 mg every 8 hours as needed for up to 3 days. Alternatively, a single dose of 100 mg followed by 50 mg doses if needed. Maximum daily dose is 200 mg.
Dosing for extended-release formulations differs and should be consulted for specific products.
## Pediatric Dosing
Dosing in pediatric patients is not well-established for most indications and formulations. Consult specific product labeling or pediatric references for available data, typically for rheumatologic conditions.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. May require dose reduction.
* **Renal Impairment:** Use with caution. Avoid in severe renal impairment.
## Contraindications
* Known hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active gastrointestinal ulcer or bleeding.
* History of GI ulcer or bleeding with previous NSAID use.
* Severe hepatic or renal impairment.
* Heart failure.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, constipation, abdominal pain, indigestion, headache, dizziness.
* **Serious:** Gastrointestinal bleeding, perforation, ulceration; cardiovascular thrombotic events (MI, stroke); renal failure; hepatic failure; hypersensitivity reactions; Stevens-Johnson syndrome; toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, Beta-blockers:** Decreased antihypertensive effect; increased risk of renal impairment.
* **Diuretics:** Decreased diuretic effect; increased risk of renal impairment.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate levels and toxicity.
## Monitoring
* **Gastrointestinal:** Monitor for signs and symptoms of GI bleeding (e.g., melena, hematemesis).
* **Cardiovascular:** Assess for signs of thrombotic events.
* **Renal:** Monitor renal function (BUN, creatinine) especially in patients with risk factors.
* **Hepatic:** Monitor liver function tests (AST, ALT) especially with long-term use or in patients with pre-existing liver disease.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Administer with food or milk to reduce gastric upset.
* Avoid concurrent use with other NSAIDs.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
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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 verify dosages and safety information prior to patient care.
