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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Pain relief (mild to moderate)
* Inflammation associated with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and other musculoskeletal conditions.
* Acute pain.
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release (IR): 150 mg daily divided into 2 or 3 doses (e.g., 50 mg twice or three times daily). Maximum 200 mg/day.
* Delayed-release (DR): 75 mg twice daily (total 150 mg/day) or 100 mg once daily. Maximum 200 mg/day.
* Extended-release (ER): 100 mg once daily. Maximum 100 mg/day.
* **Acute Pain:**
* IR: 50 mg every 8 hours as needed. Maximum 150 mg/day.
* ER: Not typically used for acute pain.
* **Migraine:**
* IR: 100 mg as a single dose.
## Pediatric Dosing
Dosing is not well-established for diclofenac oral formulations in pediatric patients. Use with caution and at the lowest effective dose for the shortest duration necessary.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Avoid in severe renal impairment. Monitor renal function.
## 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 (nausea, dyspepsia, diarrhea), dizziness, headache.
* **Serious:**
* Cardiovascular thrombotic events (MI, stroke)
* Gastrointestinal bleeding, ulceration, and perforation
* Hepatotoxicity
* Renal toxicity
* Hypertension
* Fluid retention and edema
* Serious skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis)
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, heparin, DOACs):** Increased risk of bleeding.
* **Aspirin:** Increased risk of GI bleeding. Diclofenac can interfere with aspirin's cardioprotective effect.
* **Corticosteroids:** Increased risk of GI bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **Diuretics, ACE inhibitors, ARBs:** Reduced antihypertensive effect, increased risk of renal impairment.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac levels.
## Monitoring
* Signs and symptoms of GI bleeding or ulceration.
* Renal function (BUN, creatinine).
* Liver function (ALT, AST).
* Blood pressure.
* Signs of fluid retention.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotection (e.g., PPI) for patients at high risk of GI events.
* Avoid concomitant use with other NSAIDs.
* Patients with cardiovascular disease or risk factors should use diclofenac with caution and at the lowest effective dose.
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***Disclaimer:*** *This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant guidelines for complete details and to verify dosing and safety before administering any medication.*
