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## Diclofenac
### Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation management.
### Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
### Adult Dosing
* **Osteoarthritis/Rheumatoid Arthritis/Ankylosing Spondylitis:** 50 mg two to three times daily, or 75 mg twice daily. Maximum 225 mg/day.
* **Acute Pain/Primary Dysmenorrhea:** Initial dose of 50 mg, followed by 50 mg every 8 hours as needed. Maximum 200 mg/day for the first day, then 150 mg/day thereafter.
### Pediatric Dosing
* **Rheumatoid Arthritis:** 1-3 mg/kg/day divided into 2-4 doses. Maximum 75 mg/day. (Age: 2-12 years).
* **Other indications:** Dosing is not well-established in children for indications other than rheumatoid arthritis.
### Dose Adjustments
* **Hepatic Impairment:** Use with caution, may require dose reduction.
* **Renal Impairment:** Use with caution.
### 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.
* Severe hepatic or renal impairment.
* Pregnancy (third trimester).
### Adverse Effects
* **Common:** Gastrointestinal upset (nausea, vomiting, diarrhea), abdominal pain, dyspepsia, elevated liver enzymes.
* **Serious:** Cardiovascular events (MI, stroke), GI bleeding/perforation, renal failure, hypersensitivity reactions, Stevens-Johnson syndrome.
### Key Drug Interactions
* **Anticoagulants (e.g., warfarin, heparin):** 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 lithium levels.
* **Methotrexate:** Increased methotrexate levels and toxicity.
### Monitoring
* Renal function (BUN, creatinine).
* Liver function tests (AST, ALT).
* Hemoglobin/hematocrit for signs of GI bleeding.
* Blood pressure.
### Clinical Pearls
* Administer with food or milk to minimize GI upset.
* Lowest effective dose for the shortest duration should be used to minimize cardiovascular and GI risks.
* Consider gastroprotective agents (e.g., PPI) for patients at increased risk of GI complications.
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*Disclaimer: This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines before making any treatment decisions.*
