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# Diclofenac (Oral)
## 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.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release: 50 mg orally two to three times daily.
* Delayed-release: 75 mg orally twice daily.
* Extended-release: 100 mg orally once daily.
* **Acute Pain:**
* Initial dose: 50 mg orally, followed by 50 mg every 8 hours as needed.
* Maximum daily dose for acute pain: 150 mg.
**Maximum daily dose for chronic use:** 150 mg orally.
## Pediatric Dosing
Dosing in pediatric patients is not well-established. Diclofenac is generally not recommended for use in children under 16 years of age for rheumatoid arthritis, and its use in other pediatric indications is limited and requires careful consideration by a specialist.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Starting dose may need to be reduced. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function closely. Avoid in severe renal impairment.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of bronchospasm, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
## Adverse Effects
* **Common:** Abdominal pain, nausea, vomiting, diarrhea, constipation, dyspepsia, flatulence, dizziness, headache.
* **Serious:** Cardiovascular thrombotic events (myocardial infarction, stroke), gastrointestinal bleeding, ulceration, perforation, hepatic failure, renal failure, hypertension, fluid retention, edema, hypersensitivity reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **ACE inhibitors, ARBs, diuretics:** Increased risk of renal impairment.
* **Anticoagulants (e.g., warfarin), antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **CYP2C9 inhibitors (e.g., fluconazole):** May increase diclofenac exposure.
## Monitoring
* Signs and symptoms of GI bleeding or ulceration.
* Liver function tests (LFTs) especially in patients with pre-existing liver disease or those on long-term therapy.
* Renal function tests (serum creatinine, BUN) especially in patients with pre-existing renal disease, heart failure, dehydration, or those taking diuretics or ACE inhibitors.
* Blood pressure.
* Signs of cardiovascular events.
## Clinical Pearls
* The lowest effective dose should be used for the shortest duration necessary to minimize the risk of serious adverse events.
* Use with food or milk to decrease GI upset.
* Patients should be advised to report any signs of GI bleeding (e.g., black, tarry stools, vomiting blood) or cardiovascular events immediately.
* Risk of serious cardiovascular thrombotic events is increased with higher doses and longer duration of use.
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This information is intended for healthcare professionals and should not be used as a substitute for professional medical advice. Always consult the most current prescribing information and relevant literature, and consider individual patient factors when making therapeutic decisions.
