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## Diclofenac
### Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
### Primary Indications
* Rheumatoid arthritis
* Osteoarthritis
* Ankylosing spondylitis
* Acute pain
* Menstrual pain (dysmenorrhea)
### Adult Dosing
* **Rheumatoid Arthritis, Osteoarthritis, Ankylosing Spondylitis:** 150 mg to 200 mg daily, divided into 2 to 4 doses. Maximum recommended daily dose is 225 mg.
* **Acute Pain:** Initial dose of 50 mg, followed by 50 mg every 8 hours as needed. Alternatively, 75 mg given as a delayed-release formulation twice daily. Maximum daily dose is 150 mg for short-term use.
* **Primary Dysmenorrhea:** Initial dose of 50 mg, followed by 50 mg every 8 hours as needed. Maximum daily dose is 200 mg.
### Pediatric Dosing
* **Juvenile Idiopathic Arthritis:** Generally 1 mg/kg/day to 3 mg/kg/day in 2 to 4 divided doses. Maximum daily dose is 150 mg. Specific dosing depends on local protocol and formulation availability.
### Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild to moderate impairment may not require dose adjustment, but monitor closely. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function. May require dose reduction, especially in patients with pre-existing renal disease. Avoid use in severe renal impairment.
* **Elderly:** Increased risk of gastrointestinal bleeding, renal and cardiovascular events. Use the lowest effective dose for the shortest duration.
### Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of bronchospasm, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Inflammatory bowel disease (active or history).
* Severe heart failure, severe renal impairment, severe hepatic impairment.
### Adverse Effects
* **Common:** Gastrointestinal upset (dyspepsia, nausea, diarrhea), headache, dizziness, rash.
* **Serious:** Gastrointestinal bleeding and ulceration, cardiovascular thrombotic events (MI, stroke), renal toxicity, hepatic injury, hypersensitivity reactions, fluid retention, edema, hypertension.
### Key Drug Interactions
* **Anticoagulants (e.g., warfarin) and Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of gastrointestinal ulceration and bleeding.
* **ACE Inhibitors, Angiotensin Receptor Blockers (ARBs), Diuretics:** May reduce antihypertensive effect and increase risk of renal toxicity.
* **Lithium, Methotrexate:** Increased serum concentrations and toxicity.
* **Other NSAIDs:** Increased risk of adverse effects.
### Monitoring
* Renal function (creatinine, BUN).
* Liver function tests (ALT, AST).
* Complete blood count (CBC) for signs of bleeding.
* Blood pressure.
* Signs and symptoms of gastrointestinal bleeding or ulceration.
* Signs of fluid retention or edema.
### Clinical Pearls
* Administer with food or milk to minimize gastrointestinal upset.
* Use the lowest effective dose for the shortest duration necessary.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
* Avoid concomitant use with other NSAIDs.
* Monitor patients closely for signs of cardiovascular, renal, and gastrointestinal toxicity, especially with long-term use.
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*This information is intended for clinical use and does not substitute for professional medical judgment. Always verify current prescribing information with the latest official drug compendia.*
