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# Diclofenac
## Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain relief and to reduce inflammation.
## Primary Indications
* Mild to moderate pain
* Osteoarthritis
* Rheumatoid arthritis
* Ankylosing spondylitis
* Dysmenorrhea
## Adult Dosing
* **Oral:**
* Immediate-release: 25 mg to 50 mg orally two to three times daily. Maximum dose: 200 mg/day.
* Delayed-release: 25 mg to 75 mg orally twice daily. Maximum dose: 225 mg/day.
* Extended-release: 75 mg to 100 mg orally once daily. Maximum dose: 100 mg/day.
* **Topical:**
* Gel/Solution: Apply to affected areas as directed (e.g., 1% gel for extremities, 1.5% gel for knees, 2% solution for knees). Frequency varies by product.
* **Ophthalmic:**
* 1% solution: 1 drop instilled into the affected eye every 4 to 6 hours as needed for pain or inflammation.
## Pediatric Dosing
* **Oral:** Generally not recommended for children under 14 years for anti-inflammatory indications due to lack of established dosing and safety data. For pain relief in children 14 years and older, doses similar to adults may be used, typically 25 mg three times daily.
## Dose Adjustments
* **Hepatic Impairment:** Use with caution. Consider a lower initial dose.
* **Renal Impairment:** Use with caution. Monitor renal function. Not recommended 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.
* Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery.
## Adverse Effects
Common: Abdominal pain, nausea, indigestion, diarrhea, constipation, headache, dizziness.
Serious: Cardiovascular thrombotic events, myocardial infarction, stroke, gastrointestinal bleeding, ulceration, perforation, renal injury, hepatic failure, anaphylaxis, severe skin reactions.
## Key Drug Interactions
* **ACE inhibitors/ARBs:** Increased risk of renal impairment.
* **Anticoagulants (e.g., warfarin), Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **Diuretics:** Reduced efficacy and increased risk of renal toxicity.
* **Lithium:** Increased serum lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **CYP2C9 inhibitors/inducers:** May alter diclofenac levels.
## Monitoring
* Renal function (BUN, creatinine)
* Liver function (AST, ALT)
* Complete blood count (CBC)
* Signs and symptoms of GI bleeding or ulceration
* Blood pressure
## Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Consider the increased risk of cardiovascular events, especially with long-term use or higher doses.
* Advise patients to report signs of GI bleeding (black, tarry stools; bloody vomit) or cardiovascular events (chest pain, shortness of breath).
* Topical diclofenac may have a lower systemic absorption and potentially fewer GI side effects compared to oral formulations, but local skin reactions can occur.
**Disclaimer:** This information is for clinical pharmacists and should not replace individual clinical judgment or the most current prescribing information. Always verify with the official drug label or a reliable drug information resource.
