Diclofenac
General Information
Diclofenac is the Most Commonly Used NSAID Worldwide
Indications
Arthritis Dysmenorrhea (see Dysmenorrhea )Fever (see Fever )Pain Post-Operative Pain Soft Tissue/Musculoskeletal Injury To Decrease the Risk of Malignancy
Contraindications
Pharmacology
Administration
Dose Adjustment
Adverse Effects
Endocrinologic Adverse Effects
Drug-Induced Hyporeninemic Hypoaldosteronism (see Hypoaldosteronism )
Physiology Class effect, common to all NSAID’s Dose-dependent COX-inhibition -> decreased renal prostaglandin synthesis -> results in drug-induced hyporeninemic hypoaldosteronism Clinical
Gastrointestinal/Hepatic Manifestations
Fulminant Hepatic Failure with Massive Hepatic Necrosis(see Fulminant Hepatic Failure )
Physiology : class effect, common to all NSAID’s
Transaminitis/Elevated Liver Function Tests (LFT’s) (see Drug-Induced Hepatotoxicity )
Epidemiology Class Effect : while transaminitis is common to all NSAID’s, diclofenac appears to induce a unique autoimmune hepatitis-like syndromeDiagnosis Anti-Nuclear Antibody (ANA) : positiveLiver Biopsy : consistent with chronic active hepatitisClinical : resembles autoimmune hepatitisTreatment : change to another NSAID class (such as naproxen, etc) appears to be safe
Hematologic Manifestations
Pulmonary Adverse Effects
Aspirin-Intolerant Asthma (see Asthma )
Physiology : class effect, common to multiple NSAID’s
Associated Agents Acetylsalicylic Acid (Aspirin) (see Acetylsalicylic Acid )Diclofenac (Aclonac, Cataflam, Voltaren) (see Diclofenac )Diflunisal (Dolobid) Fenbufen Fenoprofen (see Fenoprofen ): case reportsIbuprofen (Advil, Brufen, Motrin, Nurofen) (see Ibuprofen ): case reportsIndomethacin (Indocin) (see Indomethacin )Loxoprofen Meloxicam (see Meloxicam )Naproxen (Naprosyn, Aleve) (see Naproxen ): appears to be more frequent with naproxen than other NSAID’sNimesulide Phenylbutazone Piroxicam (Feldene) (see Piroxicam )Pranoprofen Sulindac (Clinoril) (see Sulindac ): case reportsTenidap Tiaprofenic Acid Tolfenamic Acid Diagnosis Lung Biopsy : poorly defined granulomas with infiltrating eosinophilsClinical Cough Dyspnea Fever Peripheral Eosinophilia Pulmonary Infiltrates
Renal Adverse Effects
Physiology : class effect, common to all NSAID’s
Mechanism : due to drug-induced hyporeninemic hypoaldosteronism
Increased Renal Sodium Reabsorption with Peripheral Edema
Risk Factors Physiology : decreased PGE2 -> increased renal sodium reabsorptionClass Effect : common to all NSAID’sDose-Dependent Effect Clinical : typically occurs during the first week of therapy
Physiology : due to NSAID-induced hyporeninemic hypoaldosteronismClinical
Other Adverse Effects
References
Diclofenac induced hepatitis. 3 cases with features of autoimmune chronic active hepatitis. Dig Dis Sci. 1993;38(4):744 [MEDLINE ] Drug-induced immune haemolytic anaemia in the Berlin Case-Control Surveillance Study. Br J Haematol 2011; 154:644-653. Doi: 10.1111/j.1365-2141.2011.08784.x; First published online 12 July 2011 [MEDLINE ]
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