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# Diclofenac
## Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
## Primary Indications
* Mild to moderate pain
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Dysmenorrhea
## Adult Dosing
* **Oral:**
* Immediate-release: 25 mg to 50 mg three to four times daily. Maximum daily dose is 200 mg.
* Delayed-release: 75 mg twice daily or 50 mg three times daily. Maximum daily dose is 225 mg.
* Extended-release: 100 mg once daily. Maximum daily dose is 100 mg.
* **Topical:** (e.g., gel, patch)
* Apply to affected area as directed by product labeling, typically 1% to 2% strength, a few times daily.
## Pediatric Dosing
* **Oral:**
* Children 2 to 12 years: 1 mg/kg/day divided into three or four doses. Maximum daily dose is 3 mg/kg/day or 100 mg/day, whichever is less.
* Limited data for other age groups and indications.
## Dose Adjustments
* **Renal Impairment:** Use with caution. Not recommended for severe renal impairment.
* **Hepatic Impairment:** Use with caution. Not recommended for severe hepatic impairment. Dose reduction may be necessary.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active peptic ulceration or gastrointestinal bleeding.
* History of gastrointestinal bleeding or perforation related to prior NSAID use.
* Severe heart failure.
* Third trimester of pregnancy.
## Adverse Effects
* **Common:** Gastrointestinal upset (nausea, vomiting, diarrhea, constipation, abdominal pain), dizziness, headache.
* **Serious:** Gastrointestinal bleeding, ulceration, perforation, cardiovascular thrombotic events (MI, stroke), renal toxicity, hepatic toxicity, 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.
* **SSRIs/SNRIs:** Increased risk of gastrointestinal bleeding.
* **ACE inhibitors, ARBs, diuretics:** May reduce antihypertensive effect and increase risk of renal impairment.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
## Monitoring
* Signs and symptoms of gastrointestinal bleeding (e.g., melena, hematemesis).
* Renal function (e.g., BUN, creatinine).
* Liver function (e.g., AST, ALT).
* Blood pressure.
* Signs of cardiovascular events.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotection (e.g., PPI) in patients at increased risk for GI events.
* Monitor for fluid retention and edema, especially in patients with heart failure or hypertension.
* Discontinue if any signs of severe hepatic or renal dysfunction, or cardiovascular event occur.
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*Please verify current prescribing information and local protocols for definitive dosing and usage guidelines.*
