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# Diclofenac (Oral)
## Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation.
## Primary Indications
* Mild to moderate pain
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Dysmenorrhea
## Adult Dosing
* **Pain and Dysmenorrhea:** 50 mg three times daily as needed.
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg two to three times daily, or 75 mg twice daily.
* **Maximum Daily Dose:** 225 mg per day.
## Pediatric Dosing
* **Rheumatoid Arthritis:** 1-3 mg/kg/day divided into 2-4 doses. Maximum daily dose is 75 mg.
* *Note: Oral diclofenac is not generally recommended for children under 1 year of age.*
## Dose Adjustments
* **Renal Impairment:** Use with caution. No specific dose adjustment is usually recommended for mild to moderate impairment, but close monitoring is advised. Avoid in severe renal impairment.
* **Hepatic Impairment:** Use with caution. Start at the lower end of the dosing range. Avoid in severe hepatic impairment.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of bronchospasm, asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
## Adverse Effects
* **Common:** Abdominal pain, nausea, dyspepsia, diarrhea, elevated liver enzymes.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), gastrointestinal bleeding, ulceration, perforation, renal toxicity, hepatic failure, hypersensitivity reactions, Stevens-Johnson syndrome/toxic epidermal necrolysis.
## Key Drug Interactions
* **Other NSAIDs (including aspirin):** Increased risk of GI bleeding and renal toxicity.
* **Anticoagulants (e.g., warfarin) and antiplatelets (e.g., clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **ACE inhibitors, ARBs, diuretics:** Reduced antihypertensive effect, increased risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **CYP2C9 inhibitors (e.g., fluconazole):** May increase diclofenac plasma concentrations.
## Monitoring
* **Renal function:** Monitor serum creatinine and BUN, especially in patients with risk factors for renal impairment.
* **Hepatic function:** Monitor LFTs, especially with prolonged use or in patients with pre-existing liver disease.
* **Signs and symptoms of GI bleeding:** Advise patients to report dark stools, vomiting blood, or severe stomach pain.
* **Cardiovascular risk factors:** Assess and manage appropriately.
## Clinical Pearls
* Lowest effective dose for the shortest duration should be used to minimize risk.
* Consider concomitant gastroprotection (e.g., PPI) in patients at high risk for GI events.
* Diclofenac may mask signs and symptoms of infection.
* Can increase blood pressure.
*This information is intended as a reference and does not replace professional medical judgment. Always consult the most current prescribing information and institutional guidelines before administering any medication.*
