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## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Pain and inflammation associated with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis.
* Acute pain (e.g., musculoskeletal injuries, post-operative pain, dysmenorrhea).
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally two to three times daily, or 75 mg orally twice daily. Maximum daily dose: 225 mg.
* **Acute Pain, Dysmenorrhea:** Initial dose of 50 mg orally, followed by 50 mg every 8 hours as needed. Alternatively, 100 mg orally initially, followed by 50 mg every 8 hours as needed. Maximum daily dose: 200 mg.
*Note: Delayed-release and extended-release formulations have different dosing schedules. Always consult specific product labeling.*
## Pediatric Dosing
Dosing in children is generally not recommended due to safety concerns and lack of established efficacy data for most indications. Specific pediatric use and dosing may be available for certain formulations (e.g., oral solution for juvenile idiopathic arthritis), but requires careful consideration and specialist guidance.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate impairment may not require adjustment, but monitor closely. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function. Avoid 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.
* Peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Active peptic ulceration or GI bleeding.
* Inflammatory bowel disease (active).
* Heart failure (Class III-IV).
## Adverse Effects
* **Common:** Gastrointestinal upset (dyspepsia, nausea, diarrhea), dizziness, headache.
* **Serious:**
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, and heart failure.
* **Gastrointestinal:** Ulceration, bleeding, perforation.
* **Renal:** Acute kidney injury, interstitial nephritis.
* **Hepatic:** Hepatotoxicity (rare but severe).
* **Dermatologic:** Serious skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis).
* **Hematologic:** Anemia, bruising.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Aspirin/Other NSAIDs:** Increased risk of GI toxicity and reduced cardioprotective effect of low-dose aspirin.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **Diuretics, ACE Inhibitors, ARBs:** May reduce antihypertensive effects and increase risk of renal impairment.
* **Lithium, Methotrexate:** Diclofenac can increase serum levels.
## Monitoring
* **Baseline and periodic renal function tests (serum creatinine, BUN).**
* **Baseline and periodic liver function tests (ALT, AST).**
* **Signs and symptoms of GI bleeding (occult blood in stool, melena, hematemesis).**
* **Cardiovascular risk factors and symptoms of cardiovascular events.**
* **Blood pressure.**
## Clinical Pearls
* Diclofenac has a relatively higher risk of cardiovascular events and GI toxicity compared to some other NSAIDs.
* Use the lowest effective dose for the shortest duration necessary.
* Administer with food or milk to minimize GI upset.
* Consider gastroprotective agents (e.g., PPIs) in patients with increased risk of GI complications.
* Avoid concomitant use with other NSAIDs, including aspirin unless specifically indicated for cardioprotection at a lower dose and under strict medical supervision.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant clinical guidelines before making treatment decisions.*
