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## Diclofenac (Oral)
### Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation.
### Primary Indications
* Pain and inflammation associated with osteoarthritis.
* Pain and inflammation associated with rheumatoid arthritis.
* Ankylosing spondylitis.
* Acute pain.
* Dysmenorrhea.
### Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 50 mg orally 2-3 times daily, or 75 mg orally twice daily. Maximum dose: 225 mg/day.
* **Acute Pain:** 50 mg orally 3 times daily as needed. Maximum dose: 150 mg/day for short-term use.
* **Dysmenorrhea:** 50 mg orally 3 times daily as needed. Maximum dose: 150 mg/day for short-term use.
### Pediatric Dosing
* **Rheumatoid Arthritis:** 2-3 mg/kg/day orally divided into 2-4 doses. Maximum dose: 100 mg/day.
* **Other indications:** Dosing is not well-established in pediatric populations.
### Dose Adjustments
* **Hepatic Impairment:** Use with caution. Mild hepatic impairment may not require dose adjustment, but reduce dose in moderate to severe impairment. Monitor for signs of liver toxicity.
* **Renal Impairment:** Use with caution. NSAIDs can impair renal function. Monitor renal function closely, especially in patients with pre-existing renal disease. Dose reduction may be considered in severe impairment.
### Contraindications
* Known hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Active gastrointestinal (GI) bleeding, ulceration, or perforation.
* History of GI bleeding or perforation related to previous NSAID use.
* Severe heart failure.
* Severe hepatic impairment.
* Severe renal impairment.
* Third trimester of pregnancy.
### Adverse Effects
* **Common:** Abdominal pain, nausea, vomiting, diarrhea, constipation, dyspepsia, flatulence, rash, dizziness, headache.
* **Serious:** GI bleeding, ulceration, perforation; cardiovascular thrombotic events (MI, stroke); renal impairment/failure; hepatotoxicity; hypersensitivity reactions (including anaphylaxis); hypertension; fluid retention/edema.
### Key Drug Interactions
* **Anticoagulants (e.g., warfarin) and Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI bleeding.
* **Other NSAIDs (including aspirin):** Increased risk of adverse effects, particularly GI toxicity.
* **ACE Inhibitors, ARBs, Beta-blockers:** May reduce antihypertensive effect and increase risk of renal impairment.
* **Diuretics:** May reduce diuretic effect and increase risk of renal impairment.
* **Lithium, Methotrexate:** NSAIDs can increase serum levels of these drugs.
* **CYP2C9 Inhibitors (e.g., fluconazole):** May increase diclofenac levels.
### Monitoring
* **GI:** Monitor for signs and symptoms of GI bleeding and ulceration (e.g., melena, hematemesis, abdominal pain).
* **Renal:** Monitor serum creatinine and BUN, especially in patients with risk factors for renal impairment.
* **Hepatic:** Monitor liver function tests (ALT, AST) periodically, especially in patients with pre-existing liver disease or those on long-term therapy.
* **Cardiovascular:** Monitor blood pressure and for signs of fluid retention. Assess cardiovascular risk.
### Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Consider gastroprotection (e.g., PPI) for patients at high risk of GI complications.
* Avoid in patients with a history of NSAID-induced asthma, urticaria, or allergic-type reactions.
* Use with caution in elderly patients due to increased risk of adverse events.
* Diclofenac potassium (immediate-release) may offer faster pain relief than diclofenac sodium.
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*This information is intended for healthcare professionals and does not replace professional medical advice. Always consult the most current prescribing information and your healthcare provider for any health concerns or before making any decisions related to your health or treatment.*
