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# Diclofenac (Oral) ## Overview Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. ## Primary Indications * Pain relief * Inflammation associated with conditions like rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, and acute musculoskeletal disorders. ## Adult Dosing * **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** * Immediate-release (IR): 150 mg daily, divided into 2-3 doses. Maximum: 225 mg/day. * Delayed-release (DR) or Enteric-coated (EC): 75 mg once daily or 50 mg twice daily. Maximum: 100 mg/day. * Extended-release (ER): 100 mg once daily. Maximum: 100 mg/day. * **Acute Pain or Dysmenorrhea:** * IR: 50 mg three times daily as needed. Initial dose: 50 mg, followed by 50 mg every 8 hours. Maximum: 150 mg/day for the first 2 days. * ER: 100 mg once daily. ## Pediatric Dosing Dosing in pediatric patients is not well-established for oral diclofenac. Use in children should be cautious and guided by specialist recommendations. ## Dose Adjustments * **Hepatic Impairment:** Use with caution. Start with the lowest effective dose. Avoid in severe hepatic impairment. * **Renal Impairment:** Use with caution. Monitor renal function closely. Avoid in severe renal impairment. ## Contraindications * Hypersensitivity to diclofenac, aspirin, or other NSAIDs. * Active gastrointestinal bleeding or ulceration. * History of GI bleeding or perforation related to prior NSAID use. * Perioperative pain in the setting of coronary artery bypass graft (CABG) surgery. * Severe heart failure, renal impairment, or hepatic impairment. ## Adverse Effects * **Common:** Nausea, vomiting, diarrhea, constipation, abdominal pain, dyspepsia, elevated liver enzymes, headache, dizziness. * **Serious:** Cardiovascular thrombotic events (MI, stroke), gastrointestinal bleeding, ulceration, perforation, renal toxicity, hypersensitivity reactions, fluid retention, edema. ## Key Drug Interactions * **Anticoagulants (e.g., warfarin, heparin):** Increased risk of bleeding. * **Corticosteroids:** Increased risk of GI ulceration and bleeding. * **Other NSAIDs or Salicylates:** Increased risk of GI toxicity and potentially other adverse effects. * **SSRIs/SNRIs:** Increased risk of bleeding. * **ACE inhibitors/ARBs, Diuretics:** Reduced antihypertensive effect and increased risk of renal impairment. * **Lithium:** Increased lithium levels and toxicity. * **Methotrexate:** Increased methotrexate levels and toxicity. ## Monitoring * Signs and symptoms of GI bleeding or ulceration. * Liver function tests (LFTs), especially in patients with pre-existing liver disease or elevated baseline LFTs. * Renal function (BUN, creatinine), especially in patients with renal impairment or risk factors. * Blood pressure. * Signs of cardiovascular events. ## 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. * Patients with cardiovascular risk factors should be carefully assessed before initiating diclofenac. * Avoid concomitant use with other NSAIDs. *** *This information is intended for healthcare professionals. Always verify current prescribing information and consult relevant guidelines before making clinical decisions.*