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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain, swelling, and joint stiffness. It is available in oral, topical, and injectable formulations. This information focuses on oral formulations.
## Primary Indications
* Pain associated with osteoarthritis
* Pain associated with rheumatoid arthritis
* Pain associated with ankylosing spondylitis
* Mild to moderate pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:**
* Immediate-release (IR): 50 mg two to three times daily. Maximum 200 mg/day.
* Delayed-release (DR): 75 mg two times daily. Maximum 225 mg/day.
* Extended-release (ER): 100 mg once daily. Maximum 100 mg/day.
* **Mild to Moderate Pain and Primary Dysmenorrhea:**
* IR: 50 mg three times daily as needed. Or initiate with 50 mg, followed by 50 mg every 8 hours as needed. Maximum 200 mg/day.
* DR: 50 mg three times daily as needed. Maximum 225 mg/day.
## Pediatric Dosing
Dosing in pediatric patients is not well-established for most indications. Specific formulations and doses may be used off-label or in specific age groups based on clinical judgment and available data. Consult specialized pediatric resources for guidance.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate hepatic impairment may require dose reduction; severe impairment is a contraindication.
* **Renal Impairment:** Use with caution. Consider dose reduction, especially in patients with pre-existing renal disease.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery
* History of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs
* Active gastrointestinal (GI) bleeding, ulceration, or perforation
## Adverse Effects
Common:
* Nausea, vomiting, diarrhea, constipation, abdominal pain
* Headache, dizziness
* Edema, hypertension
Serious:
* Cardiovascular thrombotic events (MI, stroke)
* Serious GI bleeding, ulceration, perforation
* Hepatotoxicity
* Renal toxicity
* Anaphylactic reactions
* Skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis)
## Key Drug Interactions
* **ACE inhibitors, ARBs, Diuretics:** Reduced antihypertensive effect, increased risk of renal impairment.
* **Corticosteroids:** Increased risk of GI bleeding and ulceration.
* **Anticoagulants (e.g., warfarin), Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **SSRIs, SNRIs:** Increased risk of bleeding.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
* **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac levels.
## Monitoring
* Monitor for signs and symptoms of GI bleeding (e.g., melena, hematemesis).
* Monitor for signs and symptoms of cardiovascular events.
* Monitor liver function tests (LFTs) and renal function tests (RFTs), especially with long-term use or in patients with risk factors.
* Monitor blood pressure.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Co-administration with a proton pump inhibitor (PPI) or misoprostol may be considered for patients at increased risk of GI events.
* Patients with heart failure, hypertension, or edema should be monitored closely.
* Discontinue if any signs of hepatic or renal impairment, or serious adverse reactions, occur.
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*Please verify current prescribing information and consult with a healthcare professional for specific patient management decisions.*
