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# Diclofenac ## Overview Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for its analgesic, anti-inflammatory, and antipyretic properties. ## Primary Indications * Pain and inflammation associated with osteoarthritis. * Pain and inflammation associated with rheumatoid arthritis. * Ankylosing spondylitis. * Mild to moderate pain. * Dysmenorrhea. ## Adult Dosing * **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** * Immediate-release: 150 mg daily, divided into 3-4 doses (e.g., 50 mg three times daily). Maximum: 225 mg daily. * Delayed-release: 75-100 mg daily, divided into 2 doses (e.g., 25 mg twice daily or 50 mg twice daily). Maximum: 150 mg daily. * Extended-release: 100 mg once daily. Maximum: 100 mg daily. * **Mild to moderate pain, Dysmenorrhea:** * Immediate-release: 50 mg three times daily as needed. May increase to 75 mg three times daily if needed. Maximum: 225 mg daily. * Delayed-release: 50 mg twice daily. Maximum: 150 mg daily. ## Pediatric Dosing * **Juvenile Idiopathic Arthritis:** * 1 to 12 years: 1-3 mg/kg/day divided into 2-4 doses. Maximum: 3 mg/kg/day or 75 mg/day, whichever is less. * **Pain and inflammation in children over 12 years:** Dosing similar to adults, typically 25 mg three times daily. *Note: Pediatric dosing for other indications is not well-established and should be guided by specialist recommendations.* ## Dose Adjustments * **Hepatic Impairment:** Use with caution. Consider a lower starting dose (e.g., 25 mg twice daily) and titrate cautiously. * **Renal Impairment:** Use with caution, especially in severe renal impairment. Monitor renal function. ## Contraindications * Known 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. * Advanced renal disease. * Advanced hepatic disease. * Severe heart failure. * Third trimester of pregnancy. ## Adverse Effects * **Common:** Gastrointestinal upset (nausea, vomiting, diarrhea, constipation, abdominal pain), dyspepsia, headache, dizziness, rash. * **Serious:** * Cardiovascular thrombotic events (myocardial infarction, stroke). * Serious gastrointestinal bleeding, ulceration, and perforation. * Hepatotoxicity (elevated liver enzymes, hepatitis, jaundice, liver failure). * Renal toxicity (acute kidney injury, interstitial nephritis, papillary necrosis). * Fluid retention and edema. * Hypertension. * Serious skin reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis). * Anaphylactic reactions. ## Key Drug Interactions * **Anticoagulants (e.g., warfarin, rivaroxaban):** Increased risk of bleeding. * **Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding. * **Corticosteroids:** Increased risk of gastrointestinal bleeding. * **SSRIs and SNRIs:** Increased risk of gastrointestinal 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 toxicity. * **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac levels. ## Monitoring * **Baseline and periodic monitoring of liver function tests (ALT, AST).** * **Baseline and periodic monitoring of renal function (creatinine, BUN).** * **Monitor for signs and symptoms of gastrointestinal bleeding (e.g., melena, hematemesis).** * **Monitor for signs and symptoms of cardiovascular events.** * **Monitor blood pressure.** ## Clinical Pearls * Use the lowest effective dose for the shortest duration necessary to minimize the risk of serious adverse effects, particularly GI bleeding and cardiovascular events. * Concomitant use of gastroprotective agents (e.g., PPIs) may be considered in patients at high risk for GI events. * Diclofenac has a boxed warning for cardiovascular thrombotic events and serious gastrointestinal bleeding. *** **Disclaimer:** This information is intended for healthcare professionals and does not substitute for professional medical advice. Always consult the most current prescribing information and relevant guidelines for complete details before making any treatment decisions.