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# Diclofenac (Oral) ## Overview Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis. It is used for pain and inflammation. ## Primary Indications * Osteoarthritis * Rheumatoid arthritis * Ankylosing spondylitis * Acute pain * Menstrual pain (dysmenorrhea) ## Adult Dosing * **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** * Enteric-coated or delayed-release tablets: 50 mg three times daily, or 75 mg twice daily. * Maximum: 225 mg daily. * **Acute Pain:** * 200 mg as a single dose on the first day of treatment, followed by 100 mg daily thereafter. * Alternatively, 50 mg three times daily. * Maximum: 150 mg daily for acute pain if given in divided doses. * **Primary Dysmenorrhea:** * Initial dose: 50 mg. * Subsequent doses: 25 mg to 50 mg every 8 hours as needed. * Maximum: 200 mg daily. * **Extended-release formulations:** Dosing varies by product, consult specific labeling. Typically 100 mg or 150 mg once daily. ## Pediatric Dosing * **Juvenile Idiopathic Arthritis (JIA):** * 1-12 years: 1-3 mg/kg/day divided into 2-3 doses. Maximum: 75 mg daily. ## Dose Adjustments * **Hepatic Impairment:** Use with caution. Start with a lower dose. Monitor for adverse effects. Not recommended in severe hepatic impairment. * **Renal Impairment:** Use with caution. Monitor renal function, especially in patients with pre-existing renal disease or risk factors (e.g., dehydration, heart failure, diuretic use). ## Contraindications * Hypersensitivity to diclofenac, aspirin, or other NSAIDs. * 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. * Active gastrointestinal bleeding or perforation. * Inflammatory bowel disease. * Heart failure (moderate to severe). * Severe hepatic or renal impairment. ## Adverse Effects * **Common:** Abdominal pain, nausea, vomiting, diarrhea, dyspepsia, constipation, flatulence, rash, dizziness, headache. * **Serious:** * Cardiovascular: Myocardial infarction, stroke, hypertension. * Gastrointestinal: Ulceration, bleeding, perforation. * Hepatic: Elevated liver enzymes, hepatitis, jaundice. * Renal: Acute kidney injury, interstitial nephritis. * Hematologic: Anemia, bruising. * Dermatologic: Stevens-Johnson syndrome, toxic epidermal necrolysis. * Hypersensitivity reactions. ## Key Drug Interactions * **Anticoagulants (e.g., warfarin):** Increased risk of bleeding. Monitor INR closely. * **Corticosteroids:** Increased risk of GI bleeding. * **SSRIs and SNRIs:** Increased risk of GI bleeding. * **Other NSAIDs or salicylates:** Increased risk of GI toxicity and additive effects. * **ACE inhibitors, ARBs, Beta-blockers, Diuretics:** Reduced antihypertensive effect and increased risk of renal impairment. * **Lithium:** Increased serum lithium levels. * **Methotrexate:** Increased risk of methotrexate toxicity. * **Cyclosporine:** Increased risk of nephrotoxicity. ## Monitoring * **Renal function:** Serum creatinine, BUN, electrolytes, especially in patients with risk factors for renal impairment or those on long-term therapy. * **Liver function:** AST, ALT, bilirubin, especially with prolonged use or if symptoms of liver dysfunction occur. * **Blood pressure:** Monitor for increases. * **Signs and symptoms of GI bleeding:** Stool guaiac, emesis, abdominal pain. * **Signs and symptoms of cardiovascular events:** Chest pain, shortness of breath, weakness. ## Clinical Pearls * Administer with food or milk to minimize GI upset. * Use the lowest effective dose for the shortest duration necessary. * Consider gastroprotection (e.g., PPI) in patients at high risk for GI events. * Be aware of increased cardiovascular risk, especially at higher doses and with prolonged use. * Patients with a history of asthma may be at increased risk for bronchospasm. *** *This information is intended for healthcare professionals. Please consult the official prescribing information and relevant literature for complete details and to verify current recommendations before making clinical decisions.*