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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Pain and inflammation associated with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis.
* Acute pain.
* Migraine.
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally three times daily OR 75 mg orally twice daily.
* **Acute Pain:** 50 mg orally every 8 hours as needed.
* **Migraine (including extended-release formulations for prophylaxis):** Dosing varies by formulation. Refer to specific product labeling.
* **Maximum Daily Dose:** 225 mg for all indications unless otherwise specified by product labeling for specific conditions like migraine prophylaxis.
## Pediatric Dosing
* **Rheumatoid Arthritis:** Dosing is weight-based and formulation-dependent. For example, the oral solution can be dosed at 2-3 mg/kg/day in divided doses, not to exceed adult doses.
* **Other indications:** Limited data in children. Use with caution and refer to specific pediatric guidelines.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Consider lower doses in mild to moderate impairment. Avoid in severe impairment.
* **Renal Impairment:** Use with caution. Consider lower doses in mild to moderate impairment. Avoid in severe impairment.
## Contraindications
* Known 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.
* Concurrent use with other NSAIDs, including COX-2 selective inhibitors.
* Active peptic ulceration or bleeding.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, elevated liver enzymes, GI bleeding (potentially serious).
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, and heart failure.
* **Renal:** Renal insufficiency, interstitial nephritis, papillary necrosis.
* **Other:** Dizziness, headache, rash, edema, hypertension.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Aspirin (low-dose):** May decrease cardioprotective effects of aspirin.
* **Corticosteroids:** Increased risk of GI adverse effects.
* **Diuretics:** May reduce diuretic efficacy and increase risk of nephrotoxicity.
* **ACE inhibitors/ARBs:** Increased risk of renal impairment.
* **Lithium/Methotrexate:** Increased serum concentrations and toxicity.
* **CYP2C9 inhibitors/inducers:** May alter diclofenac metabolism.
## Monitoring
* **Baseline and periodic assessment of renal function** (BUN, creatinine).
* **Baseline and periodic assessment of liver function** (ALT, AST).
* **Monitor for signs and symptoms of GI bleeding** (e.g., melena, hematemesis).
* **Monitor blood pressure.**
* **Monitor for signs of cardiovascular events.**
## Clinical Pearls
* Use 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.
* Consider gastroprotective agents (e.g., PPIs) in patients at increased risk for GI complications.
* NSAIDs carry a boxed warning for cardiovascular and gastrointestinal risks.
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*This information is intended for healthcare professionals and does not substitute for professional medical advice. Always consult current prescribing information and clinical guidelines before initiating or modifying drug therapy.*
