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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150-225 mg per day divided into 3 doses (e.g., 50 mg TID or 75 mg BID). Maximum recommended daily dose is 225 mg.
* **Acute Pain:** 100-150 mg per day. May start with a single 100 mg dose, followed by doses of 50 mg every 8 hours as needed. Maximum daily dose is 150 mg.
* **Primary Dysmenorrhea:** 100 mg initially, followed by 50 mg doses as needed. Maximum daily dose is 150 mg.
*Note: Lower strengths (e.g., 25 mg) are available and may be used for titration or specific indications as per local protocol.*
## Pediatric Dosing
Dosing in pediatric patients is not well-established for most indications. Refer to specific pediatric guidelines for approved uses and recommended doses if available.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Consider initiating at the lower end of the dosage range. Patients with severe hepatic impairment should generally avoid diclofenac.
* **Renal Impairment:** Use with caution. Patients with pre-existing renal disease may be at increased risk of renal toxicity. 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.
* Active gastrointestinal bleeding or perforation.
## Adverse Effects
* **Common:** Dyspepsia, nausea, abdominal pain, diarrhea, elevated liver enzymes, dizziness, headache.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), gastrointestinal bleeding, ulceration, perforation, hepatotoxicity, renal toxicity, hypersensitivity reactions, Stevens-Johnson syndrome/toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, DOACs):** 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:** Increased lithium levels and toxicity.
* **Methotrexate:** Increased risk of methotrexate toxicity.
## Monitoring
* **Baseline and periodic:** Liver function tests (AST, ALT), renal function (creatinine, BUN), complete blood count (CBC) to monitor for anemia or signs of bleeding.
* **For patients at risk:** Monitor for signs and symptoms of GI bleeding or cardiovascular events.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize the risk of adverse events.
* Administer with food or milk to reduce GI upset.
* Consider gastroprotection (e.g., PPI) for patients at high risk of GI complications.
* Be aware of the potential for cross-reactivity in patients with aspirin sensitivity.
* NSAIDs carry a boxed warning for cardiovascular thrombotic events and serious gastrointestinal events.
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***Disclaimer:** This information is intended for healthcare professionals. Always consult the current prescribing information and relevant clinical guidelines before making therapeutic decisions. Dosing may vary based on individual patient factors and local protocols.*
