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# Diclofenac (Oral)
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for the relief of signs and symptoms of osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis. It is also used for acute pain.
## Primary Indications
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
## Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally two to three times daily. Maximum daily dose is 150 mg. Alternatively, an initial dose of 75 mg twice daily can be used, with a maximum daily dose of 225 mg.
* **Acute Pain:** 50 mg orally every 8 hours as needed. Do not exceed 150 mg in a 24-hour period.
* **Enteric-coated or delayed-release formulations:** Doses may differ; consult specific product labeling.
## Pediatric Dosing
* **Rheumatoid Arthritis:** Safety and efficacy have not been established in pediatric patients.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Initiate at the lower end of the dosing range. Diclofenac is contraindicated in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function closely, especially in patients with pre-existing renal disease or those at risk for renal dysfunction (e.g., dehydration, heart failure, volume depletion). Diclofenac is contraindicated in severe renal impairment.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active gastrointestinal bleeding or perforation.
* History of GI bleeding or perforation related to prior NSAID use.
* Severe hepatic impairment.
* Severe renal impairment.
* Treatment of perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Third trimester of pregnancy.
## Adverse Effects
* **Common:** Dyspepsia, nausea, abdominal pain, headache, dizziness, rash, elevated liver enzymes.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), GI bleeding, perforation, ulceration, renal toxicity, hepatic toxicity, hypersensitivity reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, heparin):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Selective Serotonin Reuptake Inhibitors (SSRIs) / Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):** Increased risk of GI bleeding.
* **Diuretics, ACE Inhibitors, Angiotensin II Receptor Blockers (ARBs):** May diminish antihypertensive effect and increase risk of renal toxicity.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
## Monitoring
* Monitor for signs and symptoms of gastrointestinal bleeding and ulceration.
* Monitor renal function (BUN, creatinine) and electrolytes, especially in patients with risk factors.
* Monitor liver function tests (AST, ALT) periodically, especially in patients with pre-existing liver disease.
* Monitor for signs of cardiovascular events.
## Clinical Pearls
* Diclofenac should be used at the lowest effective dose for the shortest duration necessary to control symptoms.
* Consider gastroprotection (e.g., PPI) in patients at high risk for GI complications.
* Avoid concomitant use with other NSAIDs, including aspirin, unless specifically indicated and with extreme caution.
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*This information is intended for healthcare professionals. Always verify current prescribing information with the official product labeling and relevant clinical guidelines before making any treatment decisions.*
