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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain (e.g., musculoskeletal injuries, postoperative pain)
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release (IR) tablets: 150 mg daily, divided into 2 or 3 doses (e.g., 50 mg TID or 75 mg BID).
* Extended-release (ER) tablets: 100 mg once daily.
* Maximum dose: 225 mg/day for IR, 100 mg/day for ER.
* **Acute Pain, Primary Dysmenorrhea:**
* IR tablets: 50 mg TID as needed. Initial dose may be 50 mg, followed by 50 mg every 8 hours.
* Maximum dose: 200 mg/day.
## Pediatric Dosing
Dosing in children is not well-established for most indications and requires careful consideration of risks and benefits. Refer to specific pediatric guidelines or specialized literature. Some sources suggest:
* **Juvenile Idiopathic Arthritis:** Generally not recommended due to safety concerns and availability of other agents. If used, dosage is highly individualized and typically not over 2 mg/kg/day.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. May require dose reduction.
* **Renal Impairment:** Use with caution. Avoid in severe renal 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.
* Active gastrointestinal bleeding or ulceration.
## Adverse Effects
* **Common:** Abdominal pain, nausea, vomiting, diarrhea, constipation, dyspepsia, elevated liver enzymes.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), gastrointestinal bleeding/perforation, renal toxicity, hepatic failure, hypersensitivity reactions (including anaphylaxis), Stevens-Johnson syndrome/TEN, exacerbation of hypertension.
## 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:** Decreased antihypertensive effect and 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 (melena, hematemesis).
* Renal function (BUN, creatinine).
* Liver function tests (AST, ALT), especially with long-term use or in patients with pre-existing liver disease.
* Blood pressure.
* Signs of cardiovascular events.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider co-prescription of a proton pump inhibitor (PPI) or misoprostol in patients at high risk for GI complications.
* Caution in elderly patients, those with pre-existing cardiovascular disease, renal impairment, or hepatic impairment.
* May mask signs of infection.
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*This information is intended for healthcare professionals and does not replace the need to consult the most current prescribing information and relevant clinical guidelines.*
