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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, inflammation, and stiffness associated with various conditions. It works by inhibiting cyclooxygenase (COX) enzymes, which reduces the production of prostaglandins.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain (mild to moderate)
* Dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg three times daily, or 75 mg twice daily. Maximum dose: 225 mg/day.
* **Pain, Dysmenorrhea:** 50 mg every 8 hours as needed. Alternatively, an initial dose of 100 mg can be given, followed by 50 mg every 8 hours as needed. Maximum dose: 200 mg/day.
* Extended-release formulations: Typically 100 mg once daily or twice daily.
## Pediatric Dosing
* Diclofenac is generally **not recommended** for use in pediatric patients due to limited data on safety and efficacy. Specific indications and age ranges for approved pediatric use are rare and highly formulation-dependent.
## Dose Adjustments
* **Renal Impairment:** Use with caution. Severe impairment may require dose reduction or avoidance.
* **Hepatic Impairment:** Use with caution. Mild to moderate impairment may require dose reduction. Avoid in severe hepatic impairment.
## 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.
* Advanced renal disease.
* Advanced hepatic disease.
## Adverse Effects
* **Common:** Gastrointestinal upset (dyspepsia, nausea, diarrhea, constipation), abdominal pain, headache, dizziness.
* **Serious:**
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, and heart failure.
* **Gastrointestinal:** Ulceration, bleeding, perforation.
* **Renal:** Renal toxicity, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Hypersensitivity:** Anaphylaxis, severe skin reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis).
* **Hematologic:** Increased bleeding time.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, heparin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **ACE inhibitors, Angiotensin II Receptor Blockers (ARBs), Diuretics:** Decreased antihypertensive effect and increased risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **Other NSAIDs (including aspirin):** Increased risk of GI toxicity and other adverse effects.
## Monitoring
* **Renal function:** Baseline and periodic monitoring of serum creatinine and BUN, especially in patients with risk factors for renal impairment.
* **Hepatic function:** Baseline and periodic monitoring of liver enzymes (ALT, AST), especially in patients with pre-existing liver disease.
* **Gastrointestinal symptoms:** Monitor for signs and symptoms of bleeding or ulceration.
* **Cardiovascular risk factors:** Assess and manage appropriately.
## Clinical Pearls
* Administer with food or milk to minimize gastrointestinal upset.
* Use the lowest effective dose for the shortest duration necessary to minimize the risk of serious adverse events.
* Consider the risk of cardiovascular events and GI bleeding when initiating therapy, especially in higher-risk patients.
* Avoid concurrent use with other NSAIDs.
* Caution is advised in patients with dehydration, heart failure, hypertension, or systemic lupus erythematosus.
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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 and definitive guidance. Dosing and safety may vary based on individual patient factors, local protocols, and specific product formulations.*
