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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally two to three times daily, or 75 mg orally twice daily. Maximum: 150 mg/day.
* **Acute Pain:** 50 mg orally every 8 hours as needed. Maximum: 150 mg/day.
* **Primary Dysmenorrhea:** 50 mg orally three times daily as needed. Maximum: 150 mg/day.
## Pediatric Dosing
* **Pain and Inflammation (6 months to 12 years):** 1-3 mg/kg/day divided into 3-4 doses. Do not exceed adult maximum doses. For specific indications like juvenile idiopathic arthritis, refer to specialized pediatric guidelines.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution; consider lower doses. Severe hepatic impairment is generally a contraindication.
* **Renal Impairment:** Use with caution; monitor renal function closely. Avoid in severe renal impairment.
## Contraindications
* Hypersensitivity to diclofenac or other NSAIDs.
* History of asthma, urticaria, or allergic-type reactions after aspirin or other NSAIDs.
* Peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Known history of NSAID-induced gastrointestinal perforation or bleeding.
* Inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis).
* Heart failure.
* Severe hepatic or renal impairment.
* Pregnancy (third trimester).
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, GI bleeding, perforation.
* **Cardiovascular:** Increased risk of myocardial infarction and stroke.
* **Renal:** Renal insufficiency, interstitial nephritis.
* **Hepatic:** Elevated liver enzymes, hepatitis.
* **Dermatologic:** Rash, pruritus.
* **Other:** Headache, dizziness, edema, hypertension.
## Key Drug Interactions
* **ACE Inhibitors/ARBs:** Increased risk of renal dysfunction.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate toxicity.
* **Diuretics:** Decreased diuretic efficacy and increased risk of renal toxicity.
## Monitoring
* Baseline and periodic renal function tests (creatinine, BUN).
* Baseline and periodic liver function tests (ALT, AST).
* Complete blood count (CBC) to monitor for anemia or occult bleeding.
* Blood pressure.
* Signs and symptoms of GI bleeding or perforation.
* Signs and symptoms of cardiovascular events.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Administer with food or milk to minimize GI upset.
* Consider gastroprotection (e.g., PPI) in patients with increased risk of GI events.
* NSAIDs can mask signs of infection.
* Dosing frequency may vary depending on the specific formulation (e.g., delayed-release, extended-release).
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*This information is intended for healthcare professionals. Always verify current prescribing information and consult relevant clinical guidelines before making therapeutic decisions.*
