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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce inflammation and pain. It works by inhibiting cyclooxygenase (COX) enzymes, thereby decreasing prostaglandin synthesis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain (acute and chronic)
* Dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release (IR): 150 mg daily, divided into 3 or 4 doses. A typical starting dose is 50 mg two to three times daily. Maximum dose: 200 mg daily.
* Delayed-release (DR) or Enteric-coated (EC): 75 mg twice daily or 100 mg once daily. Maximum dose: 200 mg daily.
* Extended-release (ER): 100 mg once daily. Maximum dose: 100 mg daily.
* **Pain and Dysmenorrhea:**
* IR: 50 mg three times daily as needed.
* DR/EC: 100 mg initially, followed by 50 mg every 8 hours as needed.
* ER: 100 mg once daily.
* Maximum acute pain dose: 200 mg daily.
## Pediatric Dosing
Dosing in children is generally not recommended or established for most oral formulations due to safety concerns and lack of data. Specific formulations and indications may have pediatric dosing available, requiring consultation of specific product labeling.
## Dose Adjustments
* **Renal Impairment:** Use with caution. No specific dose adjustment is typically recommended for mild to moderate impairment, but monitor renal function closely. Avoid use in severe renal impairment.
* **Hepatic Impairment:** Use with caution. Consider a lower starting dose and monitor liver function. Avoid use in severe hepatic impairment.
* **Elderly:** Increased risk of adverse effects. Consider a lower dose and use with caution.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, other NSAIDs, or any component of the formulation.
* History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Inflammatory bowel disease.
* Significant renal disease.
* Significant hepatic disease.
* Heart failure.
## Adverse Effects
Common:
* Gastrointestinal (GI) upset, nausea, vomiting, diarrhea, constipation, abdominal pain
* Dizziness, headache
Serious:
* Cardiovascular thrombotic events (myocardial infarction, stroke)
* GI bleeding, ulceration, perforation
* Hepatotoxicity
* Renal toxicity
* Hypertension
* Fluid retention and edema
* Anaphylactic reactions
* Dermatologic reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis)
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin) and Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):** Increased risk of GI bleeding.
* **Diuretics:** May decrease diuretic efficacy and increase risk of renal toxicity.
* **Lithium:** May increase serum lithium levels.
* **Methotrexate:** May increase methotrexate toxicity.
* **ACE inhibitors and ARBs:** May increase risk of renal impairment.
* **CYP2C9 inhibitors (e.g., fluconazole):** May increase diclofenac levels.
## Monitoring
* Renal function (BUN, creatinine)
* Liver function tests (ALT, AST)
* Complete blood count (CBC)
* Blood pressure
* Signs and symptoms of GI bleeding
* Signs and symptoms of cardiovascular events
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotection (e.g., proton pump inhibitor) in patients at high risk for GI complications.
* Monitor for signs of fluid retention, especially in patients with heart failure or hypertension.
* Avoid concomitant use with other NSAIDs.
* Educate patients on the signs and symptoms of serious adverse effects, including GI bleeding, cardiovascular events, and liver/kidney problems.
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*Disclaimer: This information is intended for clinical use and does not substitute for professional medical advice. Always verify current prescribing information with the official drug product labeling and local protocols.*
