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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, swelling, and joint stiffness caused by arthritis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain management (mild to moderate)
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally three times daily, or 75 mg orally twice daily. Maximum recommended daily dose is 225 mg.
* **Pain Management:** 25 mg orally every 4 to 6 hours as needed. For more severe pain, 50 mg orally every 4 to 6 hours as needed. Maximum recommended daily dose is 225 mg.
* **Delayed-release formulations:** Typically 50 mg to 75 mg orally once or twice daily.
* **Extended-release formulations:** Typically 100 mg orally once daily, or 75 mg orally twice daily.
## Pediatric Dosing
* **Rheumatoid Arthritis:** 2-12 years: 1-3 mg/kg/day divided into 2-4 doses. Do not exceed the adult maximum dose. Dosing is typically guided by local protocol and specialist recommendation.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate impairment: no specific dose adjustment recommended, but monitor closely. Severe impairment: generally avoided.
* **Renal Impairment:** Use with caution. Mild to moderate impairment: no specific dose adjustment recommended, but monitor closely for signs of renal toxicity. Severe impairment: generally avoided.
## 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
* **Common:** Abdominal pain, nausea, vomiting, diarrhea, constipation, dyspepsia, flatulence, headache, dizziness, rash.
* **Serious:**
* Cardiovascular thrombotic events (myocardial infarction, stroke)
* Gastrointestinal bleeding, ulceration, perforation
* Hepatotoxicity (elevated liver enzymes, jaundice, liver failure)
* Renal toxicity (acute kidney injury, interstitial nephritis)
* Anaphylaxis
* Serious skin reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis)
## Key Drug Interactions
* **ACE inhibitors, ARBs, Diuretics:** Increased risk of renal impairment.
* **Corticosteroids:** Increased risk of GI bleeding and ulceration.
* **Anticoagulants (e.g., warfarin), Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **SSRIs, SNRIs:** Increased risk of GI bleeding.
* **Lithium, Methotrexate:** Diclofenac can increase serum levels of these drugs.
## Monitoring
* **Baseline and periodic liver function tests (LFTs)**
* **Baseline and periodic renal function tests (creatinine, BUN)**
* **Complete blood count (CBC)**
* **Signs and symptoms of GI bleeding or ulceration**
* **Blood pressure**
* **Signs of fluid retention or edema**
## Clinical Pearls
* The lowest effective dose for the shortest duration necessary should be used to minimize the risk of serious adverse effects.
* Administer with food or milk to reduce gastrointestinal upset.
* Avoid concurrent use with other NSAIDs.
* Consider gastroprotection (e.g., PPI) in patients at high risk for GI complications.
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*Disclaimer: This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always verify current prescribing information from the manufacturer or reliable drug compendia before making clinical decisions.*
