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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation.
## Primary Indications
* Rheumatoid arthritis
* Osteoarthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Rheumatoid arthritis, osteoarthritis, ankylosing spondylitis:** 50 mg orally two to three times daily. Maximum daily dose: 150 mg.
* **Acute pain:** 50 mg orally every 8 hours as needed. Maximum daily dose: 150 mg.
* **Primary dysmenorrhea:** 50 mg orally at the onset of symptoms, then 50 mg every 8 hours as needed. Maximum daily dose: 150 mg.
* **Extended-release formulations:** Dosing varies by product; consult specific product information.
## Pediatric Dosing
Limited data available. Generally not recommended for use in pediatric patients unless specifically indicated and under specialist guidance.
## Dose Adjustments
* **Renal Impairment:** Use with caution. Dosing adjustments are not well-established, but lower doses may be considered in severe impairment.
* **Hepatic Impairment:** Use with caution. Dosing adjustments are not well-established, but lower doses may be considered in moderate to severe impairment.
## Contraindications
* Known hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active gastrointestinal bleeding or ulceration.
* History of GI bleeding or perforation related to previous NSAID use.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Severe hepatic or renal impairment.
* History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Congestive heart failure (NYHA Class II-IV).
* Third trimester of pregnancy.
## Adverse Effects
* **Common:** Nausea, vomiting, diarrhea, constipation, abdominal pain, dyspepsia, flatulence, headache, dizziness.
* **Serious:** Gastrointestinal bleeding/perforation, myocardial infarction, stroke, hypertension, fluid retention, edema, acute kidney injury, liver failure, severe skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis), bronchospasm, anaphylaxis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of gastrointestinal ulceration and bleeding.
* **ACE inhibitors, ARBs, Beta-blockers:** May diminish antihypertensive effect and increase risk of renal dysfunction.
* **Diuretics:** May diminish diuretic effect and increase risk of renal dysfunction.
* **Lithium:** May increase serum lithium levels.
* **Methotrexate:** May increase methotrexate toxicity.
* **SSRIs/SNRIs:** Increased risk of bleeding.
* **CYP2C9 inhibitors (e.g., fluconazole):** May increase diclofenac exposure.
## Monitoring
* **GI bleeding:** Monitor for signs and symptoms (e.g., melena, hematemesis, abdominal pain).
* **Cardiovascular events:** Monitor for signs and symptoms (e.g., chest pain, shortness of breath, weakness).
* **Renal function:** Monitor serum creatinine and BUN, especially in patients with risk factors.
* **Liver function:** Monitor liver enzymes (AST, ALT), especially with prolonged use or in patients with pre-existing liver disease.
* **Blood pressure:** Monitor for new-onset hypertension or worsening of existing hypertension.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
* Patients with cardiovascular risk factors should be carefully assessed before initiating diclofenac.
* Discontinue immediately if any signs of serious adverse effects (GI bleeding, cardiovascular event, liver failure, severe skin reaction) occur.
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***Disclaimer:** This information is intended for healthcare professionals. Always consult the current prescribing information and relevant guidelines before administering any medication. Dosing and recommendations may vary based on patient-specific factors and local protocols.*
