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# Diclofenac (Oral)
## Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation.
## Primary Indications
* Pain associated with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis.
* Acute pain.
* Primary dysmenorrhea.
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release: 150 mg daily divided into 2-3 doses (e.g., 50 mg BID to TID). Maximum 225 mg/day.
* Delayed-release: 75 mg twice daily (150 mg/day). May increase to 100 mg twice daily (200 mg/day).
* Extended-release: 100 mg once daily. May increase to 200 mg once daily.
* **Acute Pain:** 50 mg TID initially, followed by 50 mg every 8 hours as needed. Maximum 150 mg/day for the first 2 days.
* **Primary Dysmenorrhea:** 50 mg TID initially, followed by 50 mg every 8 hours as needed. Maximum 150 mg/day for the first 2 days.
## Pediatric Dosing
Dosing is not well-established for oral diclofenac in pediatric patients. Consult specialized pediatric resources.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution; dosage reduction may be warranted. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution, especially in patients with pre-existing renal disease. Monitor renal function. Avoid in severe renal impairment.
## Contraindications
* Known hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Active gastrointestinal bleeding or ulceration.
* History of GI bleeding or perforation related to prior NSAID use.
* History of recurrent stomach/duodenal ulcers or bleeding.
* Third trimester of pregnancy.
* Severe heart failure, severe hepatic impairment, severe renal impairment.
## Adverse Effects
Common: Abdominal pain, nausea, vomiting, diarrhea, dyspepsia, flatulence, rash, dizziness, headache.
Serious: Cardiovascular thrombotic events (MI, stroke), serious GI bleeding, ulceration, perforation, renal failure, hepatic failure, hypersensitivity reactions.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin), Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of bleeding.
* **ACE Inhibitors, ARBs, Beta-Blockers:** May decrease antihypertensive efficacy; increased risk of renal impairment.
* **Diuretics:** May decrease diuretic efficacy and increase risk of renal impairment.
* **Lithium, Methotrexate:** Diclofenac may increase serum concentrations.
* **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac exposure.
## Monitoring
* **GI:** Assess for signs and symptoms of GI bleeding and ulceration.
* **Cardiovascular:** Monitor for signs of MI or stroke.
* **Renal:** Monitor renal function (BUN, creatinine) especially in patients with risk factors.
* **Hepatic:** Monitor liver function tests (ALT, AST) especially in patients with pre-existing liver disease.
* **Blood Pressure:** Monitor blood pressure.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Consider gastroprotective agents (e.g., PPIs) for patients at high risk of GI complications.
* Avoid concurrent use with other NSAIDs.
* Patient education regarding signs of GI bleeding, cardiovascular events, and renal/hepatic dysfunction is crucial.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making therapeutic decisions.*
