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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for its analgesic and anti-inflammatory properties.
## Primary Indications
* Pain relief
* Inflammation associated with osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally three times daily, or 75 mg orally twice daily. Alternatively, extended-release formulations can be used at 100 mg to 150 mg once daily.
* **Pain:** 25 mg orally four times daily or 50 mg orally two to three times daily.
* **Maximum Daily Dose:** 150 mg (for immediate-release formulations).
## Pediatric Dosing
* **Rheumatoid Arthritis:** 1 mg/kg/day orally in divided doses, not to exceed 75 mg/day. For children 12 years and older, dosing is the same as adults.
## Dose Adjustments
* **Renal Impairment:** Use with caution. Data is limited, but consider a lower starting dose and close monitoring. Avoid in severe renal impairment.
* **Hepatic Impairment:** Use with caution. Data is limited, but consider a lower starting dose and close monitoring. Avoid in severe hepatic impairment.
## Contraindications
* Known 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 bleeding or perforation.
* Inflammatory bowel disease.
* History of NSAID-induced GI ulceration or bleeding.
* Congestive heart failure.
* Severe renal or hepatic impairment.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, GI bleeding, ulceration, perforation.
* **Cardiovascular:** Increased risk of thrombotic events (MI, stroke), hypertension, edema.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Renal:** Renal insufficiency, acute kidney injury.
* **Dermatologic:** Rash, pruritus, Stevens-Johnson syndrome, toxic epidermal necrolysis.
* **Other:** Headache, dizziness, tinnitus, anaphylaxis.
## Key Drug Interactions
* **ACE inhibitors, ARBs, Diuretics:** Decreased antihypertensive effect, increased risk of renal impairment.
* **Anticoagulants (e.g., warfarin, heparin), Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **SSRIs, SNRIs:** Increased risk of bleeding.
## Monitoring
* Baseline and periodic assessment of renal function (creatinine, BUN).
* Baseline and periodic assessment of hepatic function (ALT, AST).
* Monitor for signs and symptoms of GI bleeding (melena, hematemesis).
* Monitor for signs and symptoms of cardiovascular events (chest pain, shortness of breath).
* Monitor blood pressure.
## Clinical Pearls
* Consider the lowest effective dose for the shortest duration necessary to minimize risks.
* The risk of GI events is dose-dependent and increases with duration of therapy.
* NSAIDs can cause fluid retention and edema, which can be problematic in patients with heart failure or hypertension.
* Cardiovascular risk may occur early in treatment and may increase with duration.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before administering any medication. Dosing and recommendations may vary based on patient-specific factors and local protocols.*
