Diclofenac

Diclofenac is used to treat pain related to arthritis, dysmenorrhea, rheumatic diseases and other inflammatory disorders, Diclofenac is also available in topical forms and is useful for osteoarthritis but not other types of long-term musculoskeletal pain. Diclofenac may also help with actinic keratosis and with acute pain caused by minor strains, sprains and contusions. In many countries, eye drops are sold to treat acute and chronic nonbacterial inflammation of the anterior part of the eyes (such as postoperative states). The eye drops have also been used to manage pain for traumatic corneal abrasion. Diclofenac is often used to treat chronic pain associated with cancer, especially if inflammation is present. File:Voltaren tablets.jpg|Voltaren (diclofenac) 50 mg enteric coated tablets File:Diclofenac sodium IV 75mg.jpg|Dyloject (diclofenac) 2 ml for IV and IM administration File:Diclofenac sodium 100mg.jpg|Sintofarm (diclofenac) for suppository administration File:Diclofenac Topical Gel.jpg|150 gram tube diclofenac topical gel U.S. package generic ==Contraindications==

Diclofenac is contraindicated for pregnant women; for people with active stomach or duodenal ulceration or gastrointestinal bleeding; and for people undergoing coronary artery bypass surgery. ==Adverse effects==

Diclofenac consumption has been associated with significantly increased vascular and coronary risk in a study including COX-2 inhibitors, diclofenac, ibuprofen and naproxen. Upper gastrointestinal complications were also reported. Heart In 2013, a study found major vascular events were increased by about a third by diclofenac, chiefly due to an increase in major coronary events. Professor Peter Weissberg, medical director of the British Heart Foundation said, "However, the increased risk is small, and many patients with chronic debilitating pain may well feel that this small risk is worth taking to relieve their symptoms". Only aspirin was found not to increase the risk of heart disease; however, this is known to have a higher rate of gastric ulceration than diclofenac. As of January 2015, the MHRA announced that diclofenac would be reclassified as a prescription-only medicine (POM) due to the risk of cardiovascular adverse events. A 2006 large observational study of 74,838 US users of nonsteroidal anti-inflammatory drugs or coxibs found no additional cardiovascular risk from diclofenac use. A very large study of 1,028,437 Danish users of various nonsteroidal anti-inflammatory drugs or coxibs found the "Use of the nonselective NSAID diclofenac and the selective cyclooxygenase-2 inhibitor rofecoxib was associated with an increased risk of cardiovascular death (odds ratio, 1.91; 95% confidence interval, 1.62 to 2.42; and odds ratio, 1.66; 95% confidence interval, 1.06 to 2.59, respectively), with a dose-dependent increase in risk." Diclofenac is similar in COX-2 selectivity to celecoxib. Gastrointestinal • Gastrointestinal complaints are most often noted. Most patients receive a gastro-protective drug as prophylaxis during long-term treatment (misoprostol, ranitidine, or omeprazole). Liver • Liver damage occurs infrequently, and is usually reversible. Hepatitis may occur rarely without any warning symptoms and may be fatal. Patients with osteoarthritis more often develop symptomatic liver disease than patients with rheumatoid arthritis. If used for the short-term treatment of pain or fever, diclofenac has not been found more hepatotoxic than other nonsteroidal anti-inflammatory drugs. • , Endo, Novartis, and the US FDA notified healthcare professionals to add new warnings and precautions about the potential for elevation in liver function tests during treatment with all products containing diclofenac sodium. • Cases of drug-induced hepatotoxicity have been reported in the first month but can occur at any time during treatment with diclofenac. Postmarketing surveillance has reported cases of severe hepatic reactions, including liver necrosis, jaundice, fulminant hepatitis with and without jaundice, and liver failure. Some of these reported cases resulted in fatalities or liver transplantation. Kidney • Nonsteroidal anti-inflammatory drugs "are associated with adverse renal [kidney] effects caused by the reduction in synthesis of renal prostaglandins" in sensitive persons or animal species, and potentially during long-term use in nonsensitive persons if resistance to side effects decreases with age. However, this side effect cannot be avoided merely by using a COX-2 selective inhibitor because, "Both isoforms of COX, COX-1, and COX-2, are expressed in the kidney... Mental health • Mental health side effects have been reported. These symptoms are rare but exist in significant enough numbers to include as potential side effects. These include depression, anxiety, irritability, nightmares, and psychotic reactions. ==Pharmacology==

As with other nonsteroidal anti-inflammatory drugs, the primary mechanism responsible for its anti-inflammatory, antipyretic and analgesic action is thought to be inhibition of prostaglandin synthesis through COX-inhibition. The main target in the inhibition of prostaglandin synthesis appears to be the transiently expressed prostaglandin-endoperoxide synthase-2 (PGES-2), also known as cycloxygenase-2 (COX-2). That is, diclofenac is partially selective for COX-2. The reported selectivity for COX-2 varies from 1.5 to 30 depending on the source. The drug may be bacteriostatic via inhibiting bacterial DNA synthesis. Diclofenac has a relatively high lipid solubility, making it one of the few nonsteroidal anti-inflammatory drugs that are able to enter the brain by crossing the blood-brain barrier. As in the rest of the body, it is thought to exert its effect in the brain through inhibition of COX-2. Diclofenac may be a unique member of the nonsteroidal anti-inflammatory drugs in other aspects. Some evidence indicates it inhibits the lipoxygenase pathways, thus reducing the formation of leukotrienes (also pro-inflammatory autacoids). It also may inhibit phospholipase A2, which may be relevant to its mechanism of action. These additional actions may explain its high potency it is the most potent NSAID on a broad basis. Marked differences exist among nonsteroidal anti-inflammatory drugs in their selective inhibition of the two subtypes of cyclooxygenase, COX-1, and COX-2. Drug developers have focused on selective COX-2 inhibition, particularly as a way to minimize the gastrointestinal side effects of nonsteroidal anti-inflammatory drugs. However, the cardiovascular adverse effects of some COX-2 inhibitors has led to lawsuits alleging wrongful death by heart attack. Yet, other significantly COX-selective nonsteroidal anti-inflammatory drugs, such as diclofenac, have been well tolerated by most of the population. Besides the COX-inhibition, several other molecular targets of diclofenac possibly contributing to its pain-relieving actions have recently been identified. These include: • Blockage of voltage-dependent sodium channels (after activation of the channel, diclofenac inhibits its reactivation, also known as phase inhibition) • Blockage of acid-sensing ion channels (ASICs) • Positive allosteric modulation of KCNQ- and BK-potassium channels (diclofenac opens these channels, leading to hyperpolarization of the cell membrane) ==History==

Diclofenac was first synthesized by Alfred Sallmann and Rudolf Pfister in 1973. The name "diclofenac" derives from its chemical name: 2-(2,6-dichloranilino) phenylacetic acid. It was patented in Germany in 1978 by Ciba-Geigy (now Novartis). It came into medical use in the United States in 1988. GlaxoSmithKline purchased the rights in 2015. It is available as a generic medication. ==Formulations and brand names==

Diclofenac formulations are available worldwide under many different brand names. Voltaren and Voltarol contain the sodium salt of diclofenac. In the United Kingdom, Voltarol can be supplied with either the sodium salt or the potassium salt, while Cataflam, sold in some other countries, is the potassium salt only. However, Voltarol Emulgel contains diclofenac diethylammonium 1.16%, being equivalent to 1% sodium salt. In 2016, Voltarol was one of the biggest selling branded over-the-counter medications sold in Great Britain, with sales of £39.3 million. In the United States, 1% diclofenac gel was approved by the FDA in 2007 as a prescription drug for the temporary relief of the pain of osteoarthritis of joints in the hands, knees, and feet. In 2020, the FDA approved the gel formulation for nonprescription use. ==Ecological effects==

Diclofenac in animals has environmental effects. It is toxic, for example, to scavenging birds. Too, residues of the drug are found in marine and freshwater organisms, contaminated by agricultural runoff containing diclofenac. The medication has been banned for veterinary use in several countries; Meloxicam is an alternative which is safer for wildlife. Veterinary use in livestock resulted in a sharp decline in the vulture population in the Indian subcontinent – a 95% decline by 2003 and a 99.9% decline by 2008. Vultures are long-lived and slow to breed. They start breeding only at the age of six and only 50% of their young survive. Even if the Indian government ban is fully implemented, it will take many years to revive the vulture population. The mechanism of toxicity in vultures is presumed to be kidney failure; however, toxicity may be due to direct inhibition of uric acid secretion in vultures. Vultures eat the carcasses of livestock that have been administered veterinary diclofenac, and are poisoned by the accumulated chemical, as vultures do not have a particular enzyme to break down diclofenac. At a meeting of the National Wildlife Board in March 2005, the Government of India announced it intended to phase out the veterinary use of diclofenac. Steppe eagles have the same vulnerability to diclofenac as Old World vultures and are therefore at similar risk from its effects. In contrast, New World vultures, such as the turkey vulture, can tolerate at least 100 times the level of diclofenac that is lethal to Gyps species. Despite the vulture crisis, diclofenac remains available in other countries including many in Europe. It was controversially approved for veterinary use in Spain in 2013 and continues to be available, despite Spain being home to around 90% of the European vulture population and an independent simulation showing that the drug could reduce the population of vultures by 1–8% annually. Spain's medicines agency presented simulations suggesting that the number of deaths would be quite small. A paper published in 2021 identified the first authenticated death of a vulture from diclofenac in Spain, a cinereous vulture. Diclofenac is on the European Union's watch list because it pollutes the Baltic Sea. When the substance enters fresh water, it has an environmental impact and is considered more difficult to remove in wastewater treatment plants than, for example, ibuprofen. Diclofenac has been shown also to harm freshwater fish species such as rainbow trout. Harmful residues have been found in fish, blue mussels, and other aquatic organisms, where it has been found to cause damage to internal organs such as the gills, kidneys and liver. ==Veterinary use==

Diclofenac is used for livestock; such use was responsible for the Indian vulture crisis, during which in a few years 95% of the country's vulture population was killed. In many countries, agricultural use is now forbidden. Diclofenac is approved as a veterinary medication in some countries In South Asia in the 2000s, vulture populations were decimated after feeding on carcasses of livestock that had been treated with diclofenac. == Notes ==