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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Pain associated with osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
* Mild to moderate pain.
* Acute migraine.
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* **Immediate-release:** 150 mg/day divided into 2 or 3 doses. Maximum: 225 mg/day.
* **Delayed-release:** 75 mg twice daily, or 100 mg once daily. Maximum: 200 mg/day.
* **Extended-release:** 100 mg or 200 mg once daily. Maximum: 200 mg/day.
* **Mild to moderate pain:**
* **Immediate-release:** 400 mg every 8 hours as needed. A lower starting dose of 200 mg may be used.
* **Acute Migraine:**
* **Immediate-release:** 50 mg as a single dose. May repeat once after 2 hours if response is inadequate. Maximum: 100 mg/day.
## Pediatric Dosing
Dosing in pediatric patients is not well-established and depends on age and indication. Consult specific pediatric guidelines.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Consider a lower dose. Contraindicated in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Contraindicated 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.
* Third trimester of pregnancy.
* Inflammatory bowel disease.
* Active peptic ulceration or bleeding.
## Adverse Effects
* **Common:** Gastrointestinal upset (nausea, vomiting, diarrhea, constipation, dyspepsia), dizziness, headache, rash.
* **Serious:**
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, and heart failure.
* **Gastrointestinal:** Bleeding, ulceration, perforation.
* **Renal:** Acute kidney injury, interstitial nephritis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Dermatologic:** Stevens-Johnson syndrome, toxic epidermal necrolysis.
* **Hypersensitivity:** Anaphylaxis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, diuretics:** Reduced antihypertensive effect and increased risk of renal impairment.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate levels and toxicity.
* **CYP2C9 inhibitors (e.g., fluconazole):** May increase diclofenac levels.
## Monitoring
* Signs and symptoms of GI bleeding or ulceration.
* Renal function (BUN, creatinine).
* Liver function (AST, ALT).
* Blood pressure.
* Cardiovascular risk factors.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Administer with food or milk to reduce GI upset.
* Avoid concomitant use with other NSAIDs.
* Consider gastroprotection (e.g., PPI) in patients at high risk for GI complications.
* Discontinue immediately if signs of liver toxicity, renal toxicity, or cardiovascular events occur.
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*This information is intended for healthcare professionals. Always consult the current prescribing information and your institution's protocols before administering any medication.*
