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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
* Mild to moderate pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg three times daily or 75 mg twice daily. Maximum daily dose: 225 mg.
* **Pain, Primary Dysmenorrhea:** Initial dose 50 mg, then 50 mg every 8 hours as needed. Alternatively, 100 mg initially, followed by 50 mg every 8 hours as needed. Maximum daily dose: 200 mg.
## Pediatric Dosing
* **Pain and Primary Dysmenorrhea:** Generally **not recommended** for children under 12 years of age due to lack of established safety and efficacy. Some sources suggest 1 mg/kg/day divided into 2-3 doses for children aged 1-12 years for juvenile rheumatoid arthritis, but this requires specialist guidance and careful monitoring.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. No specific dose reduction is routinely recommended, but monitor closely for adverse effects.
* **Renal Impairment:** Use with caution. Monitor renal function, especially in patients with pre-existing renal disease or risk factors.
## 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.
* Third trimester of pregnancy.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, GI bleeding, ulceration.
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, hypertension.
* **Renal:** Acute kidney injury, interstitial nephritis.
* **Hepatic:** Elevated liver enzymes, hepatitis.
* **Dermatologic:** Rash, pruritus.
* **Other:** Headache, dizziness, tinnitus, fluid retention, edema.
## Key Drug Interactions
* **ACE Inhibitors/ARBs/Diuretics:** Increased risk of renal impairment.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Anticoagulants (e.g., warfarin, DOACs):** Increased risk of bleeding.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate levels and toxicity.
* **Other NSAIDs/Aspirin:** Increased risk of GI adverse effects.
## Monitoring
* **Renal function:** Baseline and periodically, especially in at-risk patients.
* **Liver function:** Baseline and periodically, especially in patients with hepatic disease.
* **Blood pressure:** Monitor regularly.
* **Signs and symptoms of GI bleeding:** Advise patients to report black, tarry stools or vomiting blood.
## Clinical Pearls
* Lowest effective dose for the shortest duration necessary should be used to minimize risks.
* Consider gastroprotection (e.g., PPI) for patients with increased GI risk factors.
* Avoid in patients with significant cardiovascular disease or risk factors, if possible.
* Discontinue immediately if signs of hepatic injury or serious cardiovascular events occur.
**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making any treatment decisions.
