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# Diclofenac (Oral)
## Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used for the relief of pain and inflammation.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain (mild to moderate)
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally two to three times daily. Alternatively, 75 mg twice daily.
* **Pain:** Initial dose of 50 mg orally, followed by 50 mg every 8 hours as needed.
* **Maximum Daily Dose:** 150 mg for arthritis indications. For pain, maximum is 150 mg/day, but typically not exceeding 100 mg/day. Some sources may allow up to 200mg/day for short-term use in specific situations, but this is less common and carries higher risk.
## Pediatric Dosing
Dosing in pediatric patients is not well-established and generally not recommended for oral formulations due to safety concerns and lack of extensive data.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate impairment may not require dose adjustment, but monitor closely. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. No specific dose adjustments are usually recommended for mild to moderate renal impairment, but monitor renal function closely. 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.
* Advanced renal disease.
* Advanced hepatic disease.
* Third trimester of pregnancy.
## Adverse Effects
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, and thrombosis.
* **Gastrointestinal:** Dyspepsia, abdominal pain, nausea, vomiting, diarrhea, constipation, peptic ulceration, GI bleeding, perforation.
* **Renal:** Renal dysfunction, acute kidney injury.
* **Hepatic:** Elevated liver enzymes, hepatitis.
* **Dermatologic:** Rash, pruritus.
* **Other:** Headache, dizziness, edema.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Aspirin:** Increased risk of GI toxicity; may reduce cardioprotective effect of low-dose aspirin.
* **Corticosteroids:** Increased risk of GI toxicity.
* **Diuretics:** May reduce diuretic effect and increase risk of nephrotoxicity.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE Inhibitors/ARBs:** Increased risk of renal impairment.
## Monitoring
* **Renal function:** Serum creatinine, BUN, urine output, especially in patients with risk factors for renal impairment.
* **Hepatic function:** Liver enzymes (ALT, AST), bilirubin, especially in patients with pre-existing liver disease or those on long-term therapy.
* **Gastrointestinal symptoms:** Monitor for signs of bleeding or ulceration.
* **Cardiovascular risk factors:** Blood pressure, signs of heart failure.
* **Bleeding:** Monitor for signs of bleeding, especially if on concomitant anticoagulants or antiplatelets.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotection (e.g., PPI) for patients at increased risk of GI complications.
* Patients with a history of cardiovascular disease or risk factors should use diclofenac with extreme caution.
* Avoid concurrent use with other NSAIDs.
* Monitor for signs of hepatic or renal toxicity, especially with long-term use or in vulnerable populations.
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*This information is intended for healthcare professionals. Please consult the official prescribing information and relevant clinical guidelines for comprehensive details and to verify current recommendations before making treatment decisions.*
