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## Diclofenac
### Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation.
### Primary Indications
* Pain associated with osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
* Mild to moderate pain.
* Primary dysmenorrhea.
### Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg daily, divided into 2 or 3 doses. Maximum: 225 mg daily.
* **Mild to Moderate Pain, Primary Dysmenorrhea:** Initial dose of 50 mg three times daily, or 75 mg twice daily. Doses may be increased to 100 mg twice daily as needed. A total daily dose exceeding 225 mg is not recommended. Some sources may recommend up to 150 mg/day for acute pain.
### Pediatric Dosing
* **Rheumatoid Arthritis:** Generally not recommended for children under 14 years of age due to limited data. For children 14 years and older, the usual dose is 2 mg/kg/day divided into 2 or 3 doses, not to exceed 150 mg/day.
### Dose Adjustments
* **Hepatic Impairment:** Use with caution. Dose reduction may be considered in patients with mild to moderate hepatic impairment. Avoid use in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function, especially in patients with pre-existing renal disease or risk factors for renal impairment. Dose reduction may be considered. Avoid use 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.
### Adverse Effects
* **Common:** Gastrointestinal upset, nausea, abdominal pain, diarrhea, constipation, dyspepsia, headache, dizziness, elevated liver enzymes.
* **Serious:** Cardiovascular thrombotic events (myocardial infarction, stroke), gastrointestinal bleeding, perforation, ulceration, renal failure, hepatotoxicity, hypersensitivity reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis.
### Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of gastrointestinal bleeding.
* **Selective Serotonin Reuptake Inhibitors (SSRIs) / Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):** Increased risk of gastrointestinal bleeding.
* **Lithium:** Diclofenac can decrease lithium clearance; monitor lithium levels.
* **Methotrexate:** Diclofenac can decrease methotrexate clearance; monitor for methotrexate toxicity.
* **Diuretics, ACE Inhibitors, Angiotensin II Receptor Blockers (ARBs):** Increased risk of renal impairment.
### Monitoring
* Signs and symptoms of gastrointestinal bleeding.
* Renal function (BUN, creatinine), especially in at-risk patients.
* Liver function tests (AST, ALT), especially with long-term use or in patients with hepatic impairment.
* Blood pressure.
* Signs and symptoms of cardiovascular events.
### Clinical Pearls
* The lowest effective dose for the shortest duration necessary should be used to minimize risks.
* Risk of cardiovascular events and gastrointestinal bleeding increases with duration of use and higher doses.
* Concurrent use with aspirin for cardioprotection may reduce the gastrointestinal protective effect of low-dose aspirin.
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*This information is intended for healthcare professionals. Please verify current prescribing information and consult with a medical professional for specific patient management.*
