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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. It inhibits cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis.
## Primary Indications
* Pain management (mild to moderate)
* Inflammation associated with conditions like osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and acute musculoskeletal injuries.
## Adult Dosing
* **Osteoarthritis:** 350 mg extended-release (ER) capsules once daily.
* **Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg immediate-release (IR) tablets three times daily, or 75 mg IR tablets twice daily.
* **Acute Pain:** 50 mg IR tablets initially, followed by 50 mg IR every 8 hours as needed for the first day. For subsequent days, 50 mg IR every 8 hours or 50 mg ER once daily.
* **Maximum Daily Dose:** Generally, 150 mg IR daily for ER formulations and 200 mg IR for IR formulations. For ER capsules (350mg), the maximum dose is 1 capsule daily.
## Pediatric Dosing
Dosing in pediatric patients is not well-established for all formulations and indications. Limited data suggests:
* **Rheumatoid Arthritis:** 1-3 mg/kg/day divided into 2-3 doses, not to exceed adult maximums.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Consider a lower starting dose. Monitor for adverse effects.
* **Renal Impairment:** Use with caution. Monitor renal function closely, especially in patients with pre-existing renal disease or those at risk.
## Contraindications
* Known hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of bronchospasm, 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.
* History of gastrointestinal bleeding or perforation related to prior NSAID use.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, GI bleeding, ulceration, perforation.
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, hypertension.
* **Renal:** Acute kidney injury, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Other:** Headache, dizziness, rash, edema, tinnitus.
## 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, diuretics:** May reduce antihypertensive effect and increase risk of renal impairment.
* **Lithium, Methotrexate:** Increased serum concentrations and toxicity.
## Monitoring
* **Renal function:** Serum creatinine, BUN.
* **Hepatic function:** Liver enzymes (AST, ALT).
* **Gastrointestinal symptoms:** Monitor for signs of bleeding or ulceration.
* **Cardiovascular risk factors:** Blood pressure, lipid profile if indicated.
* **Signs of hypersensitivity:** Rash, wheezing.
## Clinical Pearls
* Diclofenac carries a significant risk of GI and cardiovascular adverse events, similar to other NSAIDs.
* Use the lowest effective dose for the shortest duration necessary.
* Consider gastroprotection (e.g., PPI) for patients at high risk of GI complications.
* Extended-release formulations should not be crushed or chewed.
**Disclaimer:** This information is intended for healthcare professionals and does not substitute for comprehensive drug information. Always consult the most current prescribing information and institutional protocols before making clinical decisions.
