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NSAID Pregnancy: C (first/second trimester) — D (third trimester)

Diclofenac

Brand names: Voltarol, Dicloflex

Adult dose

Dose: 50mg three times daily or 75mg twice daily (modified release)
Route: Oral, PR, or topical
Frequency: Two to three times daily
Max 150mg/day. Topical gel (Voltarol): 2–4g four times daily. Suppository: 100mg PR OD.

Clinical pearls

  • Highest cardiovascular risk among NSAIDs — AVOID in established CV disease
  • Contraindicated in IHD, CVA, PAD — EMA safety review 2013
  • Topical diclofenac (Voltarol gel): excellent for localised musculoskeletal pain with minimal systemic absorption
  • IM diclofenac: effective for biliary/renal colic and acute gout in hospital setting

Contraindications

  • Established ischaemic heart disease
  • Cerebrovascular disease
  • Peripheral arterial disease
  • Active PUD
  • Severe renal/hepatic impairment
  • Third trimester pregnancy

Side effects

  • GI bleeding
  • AKI
  • Hypertension
  • Myocardial infarction
  • Stroke
  • Hepatotoxicity

Interactions

  • SSRIs — increased GI bleed risk
  • ACE inhibitors — AKI risk
  • Methotrexate — reduced excretion/toxicity
  • Ciclosporin — nephrotoxicity

Monitoring

  • Cardiovascular risk assessment before starting
  • Renal function
  • Blood pressure

Reference: EMA NSAID Cardiovascular Safety Review 2013; BNF. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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