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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation management.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Pain (mild to moderate)
* Primary dysmenorrhea
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg daily, divided into 2 or 3 doses. Typically, 50 mg BID or TID.
* **Pain, Primary Dysmenorrhea:**
* **Immediate-release:** 50 mg TID.
* **Delayed-release:** 75 mg BID.
* **Maximum Daily Dose:** 150 mg for chronic use. Higher doses (e.g., 200 mg/day) may be used for acute pain but for the shortest duration possible.
## Pediatric Dosing
* **Pain and Inflammation (Rheumatoid Arthritis):** 2-12 years: 1-3 mg/kg/day, divided into 2-4 doses. Maximum daily dose of 150 mg. *Dosing is complex and requires careful calculation.*
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate impairment: consider a lower dose. Severe impairment: avoid use.
* **Renal Impairment:** Use with caution. Mild to moderate impairment: no specific dose adjustment usually needed, but monitor renal function closely. Severe impairment: avoid use.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active peptic ulceration or bleeding.
* History of GI bleeding or perforation related to prior NSAID use.
* History of recurrent ulcer or bleeding.
* Severe heart failure.
* Severe hepatic or renal impairment.
* Third trimester of pregnancy.
## Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, ulceration, bleeding, perforation.
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, hypertension, edema.
* **Renal:** Renal insufficiency, interstitial nephritis, papillary necrosis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Dermatologic:** Rash, pruritus.
* **Hematologic:** Anemia, increased bleeding time.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, DOACs):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Other NSAIDs, Aspirin:** Increased risk of GI toxicity and other adverse effects.
* **ACE inhibitors, ARBs, diuretics:** May decrease antihypertensive effect and increase risk of renal impairment.
* **Lithium, Methotrexate:** Increased serum levels and toxicity.
## Monitoring
* **Renal function:** Serum creatinine, BUN, especially in patients with risk factors.
* **Hepatic function:** LFTs, especially in patients with pre-existing liver disease.
* **GI symptoms:** Monitor for signs of bleeding or perforation.
* **Cardiovascular risk factors:** Blood pressure, signs of fluid retention.
* **Bleeding:** Monitor for signs of bleeding, especially if on concomitant anticoagulants or antiplatelets.
## Clinical Pearls
* Lowest effective dose should be used for the shortest duration necessary to minimize risk.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
* NSAIDs can mask signs and symptoms of infection.
* Avoid in patients with aspirin-exacerbated respiratory disease.
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*Please verify current prescribing information for the most up-to-date recommendations and specific product details.*
