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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, tenderness, swelling, and stiffness associated with osteoarthritis and rheumatoid arthritis.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain (mild to moderate)
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis:** 150 mg orally per day, divided into 2 or 3 doses. Maximum dose: 200 mg/day.
* **Rheumatoid Arthritis:** 150 mg orally per day, divided into 3 doses. Maximum dose: 200 mg/day.
* **Ankylosing Spondylitis:** 100-125 mg orally per day, divided into 3 or 4 doses. Maximum dose: 125 mg/day.
* **Pain and Primary Dysmenorrhea:** Initial dose 50 mg orally three times daily. Further doses at 8-hour intervals as needed. Do not exceed 200 mg on the first day, then 150 mg/day thereafter.
## Pediatric Dosing
* **Rheumatoid Arthritis:** 1-12 years: 1-3 mg/kg/day divided into 2-4 doses. Maximum dose: 100 mg/day.
* **Pain/Dysmenorrhea:** Not established for children under 14 years.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate impairment: start at the lower end of the dosage range. Severe impairment: avoid use.
* **Renal Impairment:** Use with caution. Mild to moderate impairment: start at the lower end of the dosage range. Severe impairment: avoid use.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of bronchospasm, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Established viral hepatitis.
## Adverse Effects
* **Common:** Abdominal pain, nausea, vomiting, diarrhea, dyspepsia, elevated liver enzymes.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), gastrointestinal bleeding, perforation, ulceration, renal toxicity, hepatotoxicity, hypersensitivity reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **ACE inhibitors and ARBs:** Increased risk of renal impairment.
* **Anticoagulants (e.g., warfarin) and antiplatelets (e.g., aspirin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Lithium:** Increased lithium levels and risk of toxicity.
* **Methotrexate:** Increased methotrexate toxicity.
* **Diuretics:** Decreased diuretic efficacy and increased risk of renal toxicity.
## Monitoring
* Renal function (BUN, creatinine)
* Liver function tests (AST, ALT)
* Complete blood count (CBC)
* Signs and symptoms of GI bleeding
* Blood pressure
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize the risk of serious adverse events.
* Patients with a history of GI disease are at higher risk for bleeding. Consider concomitant gastroprotective agents.
* Risk of cardiovascular events may increase with dose and duration of use.
* Inform patients about the signs and symptoms of serious cardiovascular and GI events.
**Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant guidelines before making any treatment decisions.
