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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain and inflammation.
## Primary Indications
* Pain associated with osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain (e.g., musculoskeletal injuries, postoperative pain)
* Migraine pain
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg per day, divided into 2 or 3 doses. Usual starting dose is 50 mg two or three times daily.
* **Acute Pain:** 50 mg every 8 hours as needed. Do not exceed 150 mg in 24 hours.
* **Migraine:** 50 mg once. May repeat once after 2 hours if needed. Do not exceed 100 mg in 24 hours.
* **Extended-Release Formulations:** Typically 100 mg once daily or 200 mg once daily.
## Pediatric Dosing
Dosing in pediatric patients is not well established for most indications. Limited data suggest use in children and adolescents for juvenile idiopathic arthritis, but specific dosing requires expert consultation.
## Dose Adjustments
No specific dose adjustments are typically required for hepatic or renal impairment, but caution is advised due to potential for renal toxicity. Patients with mild to moderate hepatic impairment may benefit from a reduced dose. Avoid use in severe hepatic or renal impairment.
## Contraindications
* 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.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, abdominal pain, nausea, diarrhea, constipation, peptic ulceration, bleeding.
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, and thrombosis.
* **Renal:** Renal papillary necrosis and other renal injury.
* **Hepatic:** Elevated liver enzymes, hepatic failure.
* **Dermatologic:** Rash, pruritus.
* **Other:** Headache, dizziness, fluid retention, edema.
## Key Drug Interactions
* **ACE inhibitors and ARBs:** Increased risk of renal impairment.
* **Corticosteroids:** Increased risk of GI bleeding.
* **Anticoagulants (e.g., warfarin) and Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Lithium:** Increased lithium levels and risk of toxicity.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **Diuretics:** Reduced diuretic efficacy, increased risk of renal impairment.
## Monitoring
* **Renal Function:** Serum creatinine and BUN, especially in patients with pre-existing renal disease or those receiving concomitant nephrotoxic agents.
* **Hepatic Function:** Liver enzymes (ALT, AST), especially with chronic use or in patients with hepatic impairment.
* **Gastrointestinal Bleeding:** Signs and symptoms of bleeding (e.g., melena, hematemesis).
* **Cardiovascular Risk Factors:** Blood pressure.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize GI and cardiovascular risks.
* Take with food or milk to reduce gastrointestinal upset.
* Avoid concomitant use with other NSAIDs.
* Patient education regarding signs of GI bleeding, renal dysfunction, and cardiovascular events is crucial.
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*This information is intended for clinical use and does not replace current prescribing information. Always consult the official drug monograph and local institutional protocols for complete details.*
