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## Diclofenac (Oral)
### Overview
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used for pain relief and to reduce inflammation.
### Primary Indications
* Symptomatic relief of osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.
* Management of mild to moderate pain.
### Adult Dosing
* **Osteoarthritis:** 250 mg four times daily or 375 mg three times daily. Alternatively, extended-release formulations: 100 mg once daily.
* **Rheumatoid Arthritis, Ankylosing Spondylitis:** 250 mg four times daily or 375 mg three times daily.
* **Acute Pain:** 50 mg three times daily as needed.
* **Maximum Daily Dose:** Generally 1000 mg (immediate-release) or 150 mg (extended-release) per day, but lower maximums are often recommended to minimize risk. Follow institutional guidelines.
### Pediatric Dosing
* Not typically recommended for children under 12 years for most indications due to insufficient data and potential risks.
* Limited data exists for specific indications. Consult specialized pediatric resources if considering.
### Dose Adjustments
* **Hepatic Impairment:** Use with caution. Start at the lower end of the dose range. Avoid in severe hepatic impairment.
* **Renal Impairment:** Use with caution. Monitor renal function closely. Avoid in severe renal impairment.
### Contraindications
* Known hypersensitivity to diclofenac, aspirin, or other NSAIDs.
* History of bronchospasm, 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:** Dyspepsia, nausea, abdominal pain, diarrhea, headache, dizziness.
* **Serious:**
* **Cardiovascular:** Increased risk of myocardial infarction, stroke, hypertension.
* **Gastrointestinal:** Ulceration, bleeding, perforation. Risk increases with duration and dose.
* **Renal:** Acute kidney injury, interstitial nephritis.
* **Hepatic:** Elevated liver enzymes, hepatitis, jaundice.
* **Dermatologic:** Severe skin reactions (e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis).
* **Hematologic:** Anemia, prolonged bleeding time.
### Key Drug Interactions
* **ACE Inhibitors, ARBs, Diuretics:** May decrease antihypertensive effect and increase risk of renal impairment.
* **Corticosteroids:** Increased risk of GI bleeding.
* **Anticoagulants (e.g., warfarin), Antiplatelets (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Lithium, Methotrexate:** Diclofenac can increase serum levels of these drugs.
* **CYP2C9 Inhibitors/Inducers:** May affect diclofenac metabolism.
### Monitoring
* Signs and symptoms of GI bleeding or ulceration.
* Blood pressure.
* Renal function (BUN, creatinine).
* Liver function tests (AST, ALT).
* Signs of cardiovascular events.
### Clinical Pearls
* Use the lowest effective dose for the shortest duration necessary to minimize risks.
* Administer with food or milk to reduce GI upset.
* Consider gastroprotection (e.g., PPI) in patients with increased GI risk factors.
* Patients with pre-existing cardiovascular disease or risk factors should use diclofenac with caution.
* Avoid concomitant use with other NSAIDs.
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*This information is intended for healthcare professionals and does not substitute for clinical judgment. Always verify current prescribing information and consult relevant resources before making therapeutic decisions.*
