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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain relief and to reduce inflammation.
## Primary Indications
* Mild to moderate pain
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Dysmenorrhea
## Adult Dosing
* **Immediate-release:** 50 mg three times daily, or 75 mg twice daily. Maximum: 225 mg/day.
* **Delayed-release:** 75 mg twice daily. Maximum: 225 mg/day.
* **Extended-release:** 100 mg once daily, or 200 mg once daily. Maximum: 200 mg/day.
* **For dysmenorrhea:** 50 mg three times daily as needed, or 100 mg initially followed by 50 mg every 8 hours as needed for the first day.
## Pediatric Dosing
* **Age 14-18 years:** 75 mg twice daily for rheumatoid arthritis or osteoarthritis.
* **Age 14-18 years:** For pain and dysmenorrhea, doses are generally not established by the FDA, but off-label use may follow adult dosing with caution.
* **Under 14 years:** Safety and efficacy have not been established.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Consider lower doses. Not recommended in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function. Not recommended in severe 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
* **Common:** Gastrointestinal upset (dyspepsia, nausea, diarrhea, constipation), dizziness, headache.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), GI bleeding, ulceration, perforation, renal failure, hepatic failure, hypersensitivity reactions, anaphylaxis, severe skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis).
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Aspirin:** Increased risk of GI ulceration and bleeding. Concurrent use is generally not recommended.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Diuretics and antihypertensives:** Decreased efficacy of diuretics and antihypertensives; increased risk of renal impairment.
* **Lithium:** Increased lithium levels and toxicity.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **Other NSAIDs:** Increased risk of adverse effects.
## Monitoring
* **Baseline and periodic:** Renal function (BUN, creatinine), liver function (ALT, AST), complete blood count (CBC) for signs of anemia or GI bleeding.
* **Signs and symptoms of GI bleeding or cardiovascular events.**
## Clinical Pearls
* Consider the lowest effective dose for the shortest duration necessary to minimize risks.
* Take with food or milk to reduce gastrointestinal upset.
* Avoid concurrent use with other NSAIDs, including topical formulations.
* Patients with pre-existing cardiovascular disease or risk factors should use diclofenac with caution.
* Risk of cardiovascular events may occur early in treatment and may increase with duration of use.
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*Disclaimer: This information is intended for healthcare professionals and does not replace clinical judgment. Always refer to the most current prescribing information and consult with a qualified healthcare provider for specific patient care decisions.*
