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# Diclofenac (Oral)
## Overview
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) used for pain and inflammation management.
## Primary Indications
* Mild to moderate pain
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Acute pain
## Adult Dosing
* **Immediate-release:** 50 mg three times daily. Maximum: 150 mg/day.
* **Delayed-release:** 75 mg twice daily or 50 mg three times daily. Maximum: 225 mg/day.
* **Extended-release:** 100 mg once daily or 75 mg twice daily. Maximum: 150 mg/day.
* **Acute pain (initiation):** 50 mg every 8 hours as needed. Maximum: 150 mg/day.
* **Postoperative pain:** Dosing varies and is often part of a multimodal regimen; consult specific protocols.
## Pediatric Dosing
Diclofenac is generally not recommended in pediatric patients for pain and inflammation due to safety concerns and lack of established dosing.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Moderate impairment may require dose reduction. Severe impairment is a contraindication.
* **Renal Impairment:** Use with caution. Avoid in severe renal impairment.
## Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of asthma, 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 gastrointestinal bleeding or perforation.
* Inflammatory bowel disease (Crohn's disease, ulcerative colitis).
* Severe hepatic or renal impairment.
* Third trimester of pregnancy.
## Adverse Effects
* **Common:** Abdominal pain, nausea, dyspepsia, diarrhea, constipation, elevated liver enzymes.
* **Serious:** Cardiovascular thrombotic events (MI, stroke), gastrointestinal bleeding, ulceration, perforation, renal toxicity, hepatic failure, hypersensitivity reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis.
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, DOACs):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors/ARBs/Diuretics:** Reduced antihypertensive effect and increased risk of renal impairment.
* **Lithium:** Increased lithium levels.
* **Methotrexate:** Increased methotrexate toxicity.
## Monitoring
* **Baseline and periodic:** Renal function (serum creatinine, BUN), liver function tests (AST, ALT), complete blood count (CBC).
* **Patients with cardiovascular risk factors:** Monitor for signs/symptoms of cardiovascular events.
* **Patients with GI history:** Monitor for signs/symptoms of GI bleeding.
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider gastroprotective agents (e.g., PPIs) in patients at high risk for GI complications.
* Monitor for signs of fluid retention and edema, especially in patients with heart failure.
* Advise patients to report any signs of bleeding, unexplained weight gain, or swelling.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and clinical guidelines before making treatment decisions.*
