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# Diclofenac
## Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used for the relief of signs and symptoms of osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis. It is also used for acute pain management and primary dysmenorrhea.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally two to three times daily, or 75 mg orally twice daily. Maximum daily dose: 225 mg.
* **Acute Pain:** 50 mg orally every 8 hours as needed for the first day, then 50 mg orally every 8 to 12 hours thereafter. Maximum daily dose: 150 mg.
* **Primary Dysmenorrhea:** 50 mg orally three times daily as needed. Maximum daily dose: 150 mg.
*Note: Dosing may vary based on specific product formulation (e.g., delayed-release, extended-release, topical, ophthalmic).*
## Pediatric Dosing
* **Rheumatoid Arthritis:** 1 mg/kg/day orally divided into 2-4 doses. Maximum daily dose: 3 mg/kg/day or 75 mg/day.
* *Dosing for other indications in pediatric patients is not established.*
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. No specific dose adjustment is recommended, but monitor liver function closely. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. No specific dose adjustment is recommended, but monitor renal function. Avoid in severe renal impairment.
## 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.
* Active gastrointestinal (GI) bleeding or ulceration.
* Inflammatory bowel disease.
* Cerebrovascular disease.
* Heart failure.
## Adverse Effects
* **Common:** Abdominal pain, nausea, dyspepsia, diarrhea, constipation, headache, dizziness, rash, elevated liver enzymes.
* **Serious:** Cardiovascular thrombotic events (myocardial infarction, stroke), GI bleeding, ulceration, perforation, hepatotoxicity, renal toxicity, fluid retention, edema, hypertension, hypersensitivity reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, Beta-blockers:** Reduced antihypertensive effect, increased risk of renal impairment.
* **Diuretics:** Reduced diuretic effect, increased risk of renal impairment.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate levels and toxicity.
* **Other NSAIDs:** Additive toxicity, increased risk of adverse effects.
## Monitoring
* **Baseline and periodic liver function tests (LFTs):** Especially in patients with pre-existing liver disease or those on long-term therapy.
* **Baseline and periodic renal function tests:** Especially in patients with pre-existing renal disease, dehydration, or those on concomitant nephrotoxic agents.
* **Complete blood count (CBC):** Monitor for anemia or occult bleeding.
* **Blood pressure:** Monitor for hypertension.
* **Signs and symptoms of GI bleeding:** Such as melena, hematemesis, or abdominal pain.
* **Signs and symptoms of cardiovascular events:** Such as chest pain or shortness of breath.
## Clinical Pearls
* Diclofenac carries a boxed warning for cardiovascular thrombotic events and GI bleeding, ulceration, and perforation.
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Avoid concomitant use with other NSAIDs.
* Consider gastroprotective agents (e.g., PPIs) for patients at increased risk of GI events.
* Consider cardiovascular risk assessment before initiating therapy.
* Educate patients about signs and symptoms of serious adverse effects, including GI bleeding, cardiovascular events, and hepatotoxicity.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines for definitive guidance. Dosing and recommendations can vary based on individual patient factors and local protocols.
