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# Diclofenac
## Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used for pain and inflammation. It works by inhibiting cyclooxygenase (COX) enzymes, reducing prostaglandin synthesis.
## Primary Indications
* Pain associated with osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
* Mild to moderate pain, including dysmenorrhea.
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally three times daily, or 75 mg orally twice daily. Maximum daily dose: 225 mg.
* **Pain/Dysmenorrhea:** 50 mg orally three times daily as needed. Initial dose may be 50 mg, followed by 50 mg every 8 hours as needed. Maximum daily dose: 200 mg.
* **Delayed-release formulations:** Typically 75 mg twice daily or 50 mg three times daily.
* **Extended-release formulations:** Typically 100 mg orally once daily or 75 mg twice daily.
Dosing should be individualized to the lowest effective dose.
## Pediatric Dosing
* **Rheumatoid Arthritis:** 2 to 3 mg/kg/day divided into 2-4 doses. Maximum daily dose: 150 mg. Not recommended for children under 1 year of age.
Dosing for other indications in pediatric patients is not well-established.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Start with lower doses and monitor liver function. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function, especially in patients with pre-existing renal disease. 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.
* Treatment of perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Active peptic ulceration or gastrointestinal bleeding.
## Adverse Effects
* **Common:** Gastrointestinal upset (nausea, vomiting, diarrhea, constipation, abdominal pain), dyspepsia, elevated liver enzymes.
* **Serious:**
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, and heart failure.
* **Gastrointestinal:** Ulceration, bleeding, perforation.
* **Renal:** Acute kidney injury, interstitial nephritis.
* **Hepatic:** Hepatitis, liver failure.
* **Dermatologic:** Severe skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis).
* **Hematologic:** Anemia, increased bleeding risk.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of gastrointestinal bleeding.
* **SSRIs/SNRIs:** Increased risk of gastrointestinal bleeding.
* **ACE inhibitors, ARBs, diuretics:** Reduced antihypertensive effect and increased risk of renal impairment.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
## Monitoring
* **Liver Function Tests (LFTs):** Baseline and periodically, especially with long-term use or in patients with hepatic impairment.
* **Renal Function Tests (BUN, creatinine):** Baseline and periodically, especially in elderly patients or those with renal impairment.
* **Hemoglobin/Hematocrit:** To detect anemia, especially with long-term use.
* **Signs and symptoms of gastrointestinal bleeding or ulceration.**
* **Signs and symptoms of cardiovascular events.**
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotection (e.g., PPI) in patients at high risk for GI complications.
* Patients with cardiovascular risk factors should use diclofenac with extreme caution, if at all.
* Avoid concurrent use with other NSAIDs.
* Monitor blood pressure, especially when initiating therapy.
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*This information is intended for clinical decision-making and is not a substitute for professional medical advice. Always consult current prescribing information and relevant guidelines before making any treatment decisions.*
