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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain (e.g., musculoskeletal injuries, post-operative pain)
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis/Rheumatoid Arthritis/Ankylosing Spondylitis:** 75-100 mg daily, divided into 2-3 doses. Alternatively, 200 mg once daily (extended-release formulations).
* **Acute Pain:** 25-50 mg every 6-8 hours as needed. Maximum daily dose: 150 mg.
* **Primary Dysmenorrhea:** 50 mg three times daily as needed. Maximum daily dose: 150 mg.
**Note:** Lower doses are generally preferred, especially in elderly patients or those with risk factors for adverse effects. Extended-release formulations should not be crushed or chewed.
## Pediatric Dosing
Dosing in pediatric patients is not well-established for most formulations and indications. Consult specific pediatric guidelines or product labeling for available pediatric data, which may be limited to specific age groups and conditions (e.g., juvenile idiopathic arthritis, post-operative pain).
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Start at the lower end of the dosage range. Avoid if severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function closely. Avoid if 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.
* Peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Active gastrointestinal bleeding or perforation.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, abdominal pain, nausea, constipation, diarrhea, gastritis, peptic ulceration, GI bleeding.
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, hypertension.
* **Renal:** Renal insufficiency, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Dermatologic:** Rash, pruritus.
* **Other:** Headache, dizziness, tinnitus, fluid retention, edema.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, Beta-blockers:** Reduced antihypertensive effect; increased risk of renal dysfunction.
* **Diuretics:** Reduced diuretic effect; increased risk of renal dysfunction.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
## Monitoring
* **Renal function:** Serum creatinine, BUN, especially in patients with pre-existing renal disease or risk factors.
* **Liver function:** LFTs, especially in patients with hepatic impairment or risk factors.
* **Gastrointestinal bleeding:** Monitor for signs and symptoms (e.g., melena, hematemesis).
* **Cardiovascular risk factors:** Blood pressure, lipid profile.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize the risk of serious cardiovascular and gastrointestinal adverse events.
* Consider co-prescription of a proton pump inhibitor (PPI) or misoprostol for patients at increased risk of GI complications.
* Advise patients to report any signs of bleeding, cardiovascular events (e.g., chest pain, shortness of breath), or significant adverse reactions.
**Disclaimer:** This information is intended for healthcare professionals. Always consult the current prescribing information and relevant clinical guidelines for complete details before making any treatment decisions.
