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## Diclofenac (Oral)
### Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation.
### Primary Indications
* Pain associated with osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
* Management of mild to moderate pain.
* Acute pain, including musculoskeletal injuries.
### Adult Dosing
* **Osteoarthritis, Rheumatoid Arthritis, Ankylosing Spondylitis:** 150 mg to 200 mg per day, divided into 2 to 4 doses.
* Usual dose: 50 mg two or three times daily.
* Maximum daily dose: 200 mg.
* **Pain and Dysmenorrhea:**
* Initial dose: 50 mg three times daily.
* Alternatively, 100 mg initially, followed by 50 mg doses as needed.
* Maximum daily dose: 200 mg.
* **Delayed-release formulations:** Typically dosed twice daily.
* **Extended-release formulations:** Typically dosed once daily.
Dosing should be individualized to the lowest effective dose.
### Pediatric Dosing
* **Rheumatoid Arthritis:**
* 1 to 12 years: 1 mg/kg/day divided into 2 to 4 doses.
* Maximum daily dose: 3 mg/kg/day or 200 mg/day, whichever is less.
* Use in children is generally limited and should be under specialist guidance.
### Dose Adjustments
* **Hepatic Impairment:** Use with caution. Initiate at the lower end of the dosing range. Monitor for signs of hepatic toxicity.
* **Renal Impairment:** Use with caution. Monitor renal function.
### Contraindications
* Hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* Active gastrointestinal ulceration or bleeding.
* History of gastrointestinal bleeding or perforation related to prior NSAID use.
* Peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.
* Severe heart failure.
* Severe hepatic impairment.
* Severe renal impairment.
* Third trimester of pregnancy.
### Adverse Effects
* **Gastrointestinal:** Dyspepsia, nausea, abdominal pain, diarrhea, constipation, gastritis, peptic ulceration, GI bleeding, perforation.
* **Cardiovascular:** Hypertension, edema, increased risk of myocardial infarction and stroke.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Renal:** Renal insufficiency, interstitial nephritis, papillary necrosis.
* **Dermatologic:** Rash, pruritus.
* **Other:** Dizziness, headache, tinnitus, hypersensitivity reactions.
### Key Drug Interactions
* **Anticoagulants (e.g., warfarin):** Increased risk of bleeding. Monitor INR closely.
* **Corticosteroids:** Increased risk of GI ulceration and bleeding.
* **SSRIs/SNRIs:** Increased risk of GI bleeding.
* **ACE inhibitors, ARBs, Beta-blockers:** Reduced antihypertensive effect, increased risk of renal impairment.
* **Diuretics:** Reduced diuretic effect, increased risk of renal impairment.
* **Lithium:** Increased lithium levels. Monitor lithium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity.
* **Other NSAIDs/Aspirin:** Increased risk of GI adverse effects and potential for additive effects.
### Monitoring
* Signs and symptoms of GI bleeding (e.g., melena, hematemesis).
* Blood pressure.
* Renal function (BUN, creatinine).
* Liver function tests (ALT, AST).
* Signs of fluid retention (e.g., edema).
### Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary.
* Consider concomitant gastroprotection (e.g., PPI) in patients at high risk for GI complications.
* Cardiovascular risk increases with dose and duration of use.
* Discontinue immediately if signs of hepatic, renal, or GI toxicity occur.
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*Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment. Verify current prescribing information before making any clinical decisions.*
