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# Diclofenac ## Overview Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for the relief of mild to moderate pain and to reduce inflammation and fever. ## Primary Indications * Pain associated with osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis. * Mild to moderate pain (e.g., musculoskeletal pain, dysmenorrhea). * Fever reduction. ## Adult Dosing * **Osteoarthritis:** 350 mg PO three times daily OR 500 mg PO twice daily (extended-release). * **Rheumatoid Arthritis, Ankylosing Spondylitis:** 400-500 mg PO twice daily OR 750 mg PO once daily (extended-release). * **Mild to Moderate Pain/Fever:** 250 mg PO every 4-6 hours as needed, NOT to exceed 1000 mg in 24 hours. * **Dysmenorrhea:** 500 mg PO once, followed by 250 mg PO every 6-8 hours as needed. Max 1000 mg in 24 hours. * **Extended-release formulations:** Doses typically range from 100 mg to 200 mg once daily. * **Maximum daily dose:** Generally 1000 mg for immediate-release and 200 mg for extended-release. Specific maximums depend on indication and formulation. ## Pediatric Dosing * **Pain and Fever:** 0.5 mg/kg to 1 mg/kg PO every 6-8 hours as needed. Do not exceed 3 mg/kg/day or 100 mg/day. * **Juvenile Idiopathic Arthritis:** 1 mg/kg to 3 mg/kg/day PO divided into 2-3 doses. Do not exceed 100 mg/day. * **Note:** Use in pediatric patients is less common and should be carefully considered. ## Dose Adjustments * **Hepatic Impairment:** Use with caution. Lower doses may be appropriate. Monitor closely. * **Renal Impairment:** Use with caution. Monitor renal function. Lower doses may be appropriate. Avoid if severe impairment. * **Elderly:** Increased risk of gastrointestinal, cardiovascular, and renal adverse events. Use the lowest effective dose for the shortest duration necessary. ## 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. ## Adverse Effects * **Common:** Gastrointestinal upset (nausea, vomiting, diarrhea, constipation, abdominal pain), dyspepsia, rash, headache, dizziness, elevated liver enzymes. * **Serious:** * Cardiovascular thrombotic events (MI, stroke). * Gastrointestinal perforation, ulceration, and bleeding. * Renal toxicity (acute kidney injury, interstitial nephritis). * Hepatotoxicity. * Fluid retention and edema. * Serious skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis). ## Key Drug Interactions * **ACE Inhibitors/ARBs:** Increased risk of renal impairment. * **Anticoagulants (e.g., warfarin, DOACs):** Increased risk of bleeding. * **Aspirin (low-dose):** May decrease cardioprotective effects of aspirin; increased risk of GI bleeding. * **Corticosteroids:** Increased risk of GI ulceration and bleeding. * **Diuretics:** Decreased diuretic efficacy; increased risk of renal impairment. * **Lithium:** Increased serum lithium levels. * **Methotrexate:** Increased methotrexate toxicity. * **SSRIs/SNRIs:** Increased risk of GI bleeding. ## Monitoring * **Baseline and periodic renal function (SCr, eGFR).** * **Baseline and periodic liver function tests (AST, ALT).** * **Signs and symptoms of GI bleeding or perforation.** * **Blood pressure.** * **Signs and symptoms of cardiovascular events.** ## Clinical Pearls * Use the lowest effective dose for the shortest duration needed to minimize risks, especially cardiovascular and gastrointestinal. * Consider gastroprotection (e.g., PPI) in patients at high risk for GI events. * Avoid in patients with established cardiovascular disease or risk factors unless benefits clearly outweigh risks. * Monitor renal function closely, especially in patients with pre-existing renal disease, dehydration, or those taking concomitant nephrotoxic agents. * Effectiveness for pain is generally comparable to other NSAIDs and acetaminophen, but risk profiles vary. *** *This information is intended for healthcare professionals and does not substitute for professional medical advice. Always verify the most current prescribing information, local protocols, and patient-specific factors before making clinical decisions.*