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## Diclofenac (Oral)
### Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
### Primary Indications
* Pain and inflammation associated with osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
* Mild to moderate pain.
* Acute musculoskeletal injuries.
### Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 250 mg to 300 mg daily, divided into 2 or 3 doses. The maximum daily dose is 300 mg.
* **Mild to Moderate Pain/Acute Musculoskeletal Injuries:** 250 mg every 4 to 6 hours as needed. The maximum daily dose is 1250 mg. *Note: This indication is not typically used for routine pain management due to higher risk profile.*
### Pediatric Dosing
* **Rheumatoid Arthritis:** 1 mg/kg/day divided into 2 to 3 doses, not to exceed 3 mg/kg/day or the adult maximum.
### 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 closely, especially in patients with pre-existing renal disease or risk factors for renal dysfunction. May require dose reduction based on severity of impairment.
### Contraindications
* Known 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.
* Advanced renal disease.
* Advanced hepatic disease.
* History of gastrointestinal (GI) bleeding or perforation related to prior NSAID use.
* Inflammatory bowel disease.
* Congestive heart failure (CHF) - severe.
### Adverse Effects
* **Common:** Dyspepsia, abdominal pain, nausea, diarrhea, dizziness, headache.
* **Serious:** Cardiovascular thrombotic events (myocardial infarction, stroke), GI bleeding, ulceration, perforation, renal failure, hepatic failure, hypertension, fluid retention, edema, exacerbation of asthma, hypersensitivity reactions.
### Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Other NSAIDs (including aspirin):** Increased risk of adverse effects, especially GI bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE Inhibitors/ARBs:** Decreased antihypertensive effect, increased risk of renal impairment.
* **Diuretics:** Decreased diuretic efficacy, increased risk of renal impairment.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
### Monitoring
* Signs and symptoms of GI bleeding (melena, hematemesis).
* Renal function (BUN, creatinine).
* Liver function (ALT, AST).
* Blood pressure.
* Signs and symptoms of cardiovascular events.
* For pediatric patients, growth and development.
### Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Consider concomitant gastroprotection (e.g., PPI) in patients at high risk for GI events.
* Assess cardiovascular risk before initiating therapy.
* Be aware of potential for NSAID-exacerbated respiratory disease.
* Patients with dehydration or advanced age are at higher risk for renal adverse effects.
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*Disclaimer: This information is for educational purposes only and does not substitute for professional medical advice. Always verify current prescribing information and consult with a healthcare provider before making any treatment decisions.*
