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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release: 150 mg to 200 mg daily, divided into 2 to 4 doses. Maximum 200 mg/day.
* Delayed-release: 75 mg to 100 mg daily, divided into 2 doses. Maximum 100 mg/day.
* Extended-release: 100 mg to 200 mg once daily. Maximum 200 mg/day.
* **Acute Pain:**
* 200 mg as a single dose on the first day, then 50 mg every 8 hours as needed for pain. Alternatively, 200 mg once daily. Maximum 200 mg/day.
## Pediatric Dosing
Dosing is not well-established for oral diclofenac in pediatric patients. Use in this population is generally not recommended.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate impairment may require dose reduction. Avoid use in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Mild to moderate impairment may require dose reduction. Avoid use 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.
* Concomitant use with other NSAIDs, including cyclooxygenase-2 (COX-2) selective inhibitors.
## Adverse Effects
* **Common:** Abdominal pain, dyspepsia, nausea, diarrhea, dizziness, headache.
* **Serious:**
* Cardiovascular thrombotic events (MI, stroke)
* Gastrointestinal bleeding, ulceration, perforation
* Hepatotoxicity (elevated liver enzymes, jaundice, hepatic failure)
* Renal toxicity (acute kidney injury, interstitial nephritis)
* Hypertension
* Fluid retention and edema
* Hypersensitivity reactions (including anaphylaxis)
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Aspirin:** Increased risk of GI bleeding. Concurrent use generally not recommended, except for low-dose aspirin for cardioprotection, which may be prescribed with caution.
* **Other NSAIDs:** Increased risk of adverse effects, especially GI.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **ACE inhibitors, ARBs, Diuretics:** Reduced antihypertensive efficacy and increased risk of renal impairment.
* **Lithium:** Increased lithium levels and toxicity.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac exposure.
## Monitoring
* Monitor for signs and symptoms of GI bleeding (e.g., melena, hematemesis).
* Monitor blood pressure.
* Monitor renal function (BUN, creatinine) and electrolytes, especially in patients with risk factors for renal impairment.
* Monitor liver function tests (ALT, AST), especially with long-term use or in patients with pre-existing liver disease.
* Assess for signs of cardiovascular events.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotective agents (e.g., PPIs) for patients at increased risk of GI events.
* Avoid use in patients with established cardiovascular disease or risk factors for cardiovascular disease unless benefits clearly outweigh risks.
* Patient education regarding signs of bleeding, cardiovascular events, and liver/kidney dysfunction is crucial.
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**Disclaimer:** This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for definitive patient care decisions. This summary does not replace a thorough evaluation of the patient and their specific clinical situation.
