the potential risk for an adverse cv event in nsaid-treated patients, use the lowest effective dose for the shortest duration possible. physicians and patients should remain alert for the development of such events, throughout the entire treatment course, even in the absence of previous cv symptoms. patients should be informed about the symptoms of serious cv events and the steps to take if they occur. there is no consistent evidence that concurrent use of aspirin mitigates the increased risk of serious cv thrombotic events associated with nsaid use. the concurrent use of aspirin and an nsaid, such as diclofenac, increases the risk of serious gastrointestinal (gi) events (see warnings; gastrointestinal bleeding, ulceration, and perforation). status post-coronary artery bypass graft (cabg) surgery two large, controlled, clinical trials of cox-2 selective nsaid for the treatment of pain in the first 10 to 14 days following cabg surgery found an increased incidence of myocardial infarction and stroke. nsaids are contraindicated in the setting of cabg (see contraindications). post-mi patients observational studies conducted in the danish national registry have demonstrated that patients treated with nsaids in the post-mi period were at increased risk of reinfarction, cv-related death, and all-cause mortality beginning in the first week of treatment. in this same cohort, the incidence of death in the first year post-mi was 20 per 100 person years in nsaid-treated patients compared to 12 per 100 person years in non-nsaid-exposed patients. although the absolute rate of death declined somewhat after the first year post-mi, the increased relative risk of death in nsaid users persisted over at least the next four years of follow-up. avoid the use of diclofenac sodium extended-release tablets in patients with a recent mi unless the benefits are expected to outweigh the risk of recurrent cv thrombotic events. if diclofenac sodium extended-release tablets are used in patients with a recent mi, monitor patients for signs of cardiac ischemia. gastrointestinal bleeding, ulceration, and perforation nsaids, including diclofenac, can cause serious gastrointestinal (gi) adverse events, including inflammation, bleeding, ulceration, and perforation of the esophagus, stomach, small intestine, or large intestine, which can be fatal. these serious adverse events can occur at any time, with or without warning symptoms, in patients treated with nsaids. only one in five patients, who develop a serious upper gi adverse event on nsaid therapy, is symptomatic. upper gi ulcers, gross bleeding, or perforation caused by nsaids occurred in approximately 1% of patients treated for 3-6 months, and in about 2%-4% of patients treated for one year. however, even short-term therapy is not without risk. risk factors for gi bleeding, ulceration, and perforation patients with a prior history of peptic ulcer disease and/or gi bleeding who use nsaids had a greater than 10-fold increased risk for developing a gi bleed compared to patients without these risk factors. other factors that increase the risk of gi bleeding in patients treated with nsaids include longer duration of nsaid therapy, concomitant use of oral corticosteroids, aspirin, anticoagulants, or selective serotonin reuptake inhibitors (ssris); smoking, use of alcohol, older age, and poor general health status. most postmarketing reports of fatal gi events occurred in elderly or debilitated patients. additionally, patients with advanced liver disease and/or coagulopathy are at increased risk for gi bleeding. strategies to minimize the gi risks in nsaid-treated patients: • use the lowest effective dose for the shortest possible duration. • avoid administration of more than one nsaid at a time. • avoid use in patients at higher risk unless benefits are expected to outweigh the increased risk of bleeding. for such patients, as well as those with active gi bleeding, consider alternate therapies other than nsaids. • remain alert for signs and symptoms of gi ulceration and bleeding during nsaid therapy. • if a serious gi adverse event is suspected, promptly initiate evaluation and treatment, and discontinue diclofenac sodium extended-release tablets until a serious gi adverse event is ruled out. • in the setting of concomitant use of low-dose aspirin for cardiac prophylaxis, monitor patients more closely for evidence of gi bleeding (see precautions; drug interactions). hepatotoxicity in clinical trials of diclofenac-containing products, meaningful elevations (i.e., more than 3 times the uln) of ast (sgot) were observed in about 2% of approximately 5,700 patients at some time during diclofenac treatment (alt was not measured in all studies). in a large, open-label, controlled trial of 3,700 patients treated with oral diclofenac sodium for 2 to 6 months, patients were monitored first at 8 weeks and 1,200 patients were monitored again at 24 weeks. meaningful elevations of alt and/or ast occurred in about 4% of patients and included marked elevations (greater than 8 times the uln) in about 1% of the 3,700 patients. in that open-label study, a higher incidence of borderline (less than 3 times the uln), moderate (3 - 8 times the uln), and marked (greater than 8 times the uln) elevations of alt or ast was observed in patients receiving diclofenac when compared to other nsaids. elevations in transaminases were seen more frequently in patients with osteoarthritis than in those with rheumatoid arthritis. almost all meaningful elevations in transaminases were detected before patients became symptomatic. abnormal tests occurred during the first 2 months of therapy with diclofenac in 42 of the 51 patients in all trials who developed marked transaminase elevations. in postmarketing reports, cases of drug-induced hepatotoxicity have been reported in the first month, and in some cases, the first 2 months of therapy, 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. in a european retrospective population-based, case-controlled study, 10 cases of diclofenac associated drug-induced liver injury with current use compared with non-use of diclofenac were associated with a statistically significant 4-fold adjusted odds ratio of liver injury. in this particular study, based on an overall number of 10 cases of liver injury associated with diclofenac, the adjusted odds ratio increased further with female gender, doses of 150 mg or more, and duration of use for more than 90 days. physicians should measure transaminases at baseline and periodically in patients receiving long-term therapy with diclofenac, because severe hepatotoxicity may develop without a prodrome of distinguishing symptoms. the optimum times for making the first and subsequent transaminase measurements are not known. based on clinical trial data and postmarketing experiences, transaminases should be monitored within 4 to 8 weeks after initiating treatment with diclofenac. however, severe hepatic reactions can occur at any time during treatment with diclofenac. if abnormal liver tests persist or worsen, if clinical signs and/or symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash, abdominal pain, diarrhea, dark urine, etc.), diclofenac sodium extended-release tablets should be discontinued immediately. inform patients of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, diarrhea, pruritus, jaundice, right upper quadrant tenderness, and “flu-like” symptoms). if clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash, etc.), discontinue diclofenac sodium extended-release tablets immediately, and perform a clinical evaluation of the patient. to minimize the potential risk for an adverse liver related event in patients treated with diclofenac sodium extended-release tablets, use the lowest effective dose for the shortest duration possible. exercise caution when prescribing diclofenac sodium extended-release tablets with concomitant drugs that are known to be potentially hepatotoxic (e.g., acetaminophen, antibiotics, anti-epileptics). hypertension nsaids, including diclofenac sodium extended-release tablets, can lead to new onset of hypertension or worsening of preexisting hypertension, either of which may contribute to the increased incidence of cv events. patients taking angiotensin converting enzyme (ace) inhibitors, thiazides diuretics or loop diuretics may have impaired response to these therapies when taking nsaids (see precautions; drug interactions). monitor blood pressure (bp) during the initiation of nsaid treatment and throughout the course of therapy. heart failure and edema the coxib and traditional nsaid trialists’ collaboration meta-analysis of randomized controlled trials demonstrated an approximately two-fold increase in hospitalization for heart failure in cox-2 selective-treated patients and nonselective nsaid-treated patients compared to placebo-treated patients. in a danish national registry study of patients with heart failure, nsaid use increased the risk of mi, hospitalization for heart failure, and death. additionally, fluid retention and edema have been observed in some patients treated with nsaids. use of diclofenac may blunt the cv effects of several therapeutic agents used to treat these medical conditions (e.g., diuretics, ace inhibitors, or angiotensin receptor blockers [arbs]) (see precautions; drug interactions). avoid the use of diclofenac sodium extended-release tablets in patients with severe heart failure unless the benefits are expected to outweigh the risk of worsening heart failure. if diclofenac sodium extended-release tablets are used in patients with severe heart failure, monitor patients for signs of worsening heart failure. renal toxicity and hyperkalemia renal toxicity long-term administration of nsaids has resulted in renal papillary necrosis and other renal injury. renal toxicity has also been seen in patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion. in these patients, administration of an nsaid may cause a dose-dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decompensation. patients at greatest risk of this reaction are those with impaired renal function, dehydration, hypovolemia, heart failure, liver dysfunction, those taking diuretics and ace inhibitors or arbs, and the elderly. discontinuation of nsaid therapy is usually followed by recovery to the pretreatment state. no information is available from controlled clinical studies regarding the use of diclofenac sodium extended-release tablets in patients with advanced renal disease. the renal effects of diclofenac sodium extended-release tablets may hasten the progression of renal dysfunction in patients with preexisting renal disease. correct volume status in dehydrated or hypovolemic patients prior to initiating diclofenac sodium extended-release tablets. monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia during use of diclofenac sodium extended-release tablets (see precautions; drug interactions). avoid the use of diclofenac sodium extended-release tablets in patients with advanced renal disease unless the benefits are expected to outweigh the risk of worsening renal function. if diclofenac sodium extended-release tablets are used in patients with advanced renal disease, monitor patients for signs of worsening renal function. hyperkalemia increases in serum potassium concentration, including hyperkalemia, have been reported with use of nsaids, even in some patients without renal impairment. in patients with normal renal function, these effects have been attributed to a hyporeninemic-hypoaldosteronism state. anaphylactic reactions diclofenac has been associated with anaphylactic reactions in patients with and without known hypersensitivity to diclofenac and in patients with aspirin-sensitive asthma (see contraindications, warnings; exacerbation of asthma related to aspirin sensitivity). exacerbation of asthma related to aspirin sensitivity a subpopulation of patients with asthma may have aspirin-sensitive asthma, which may include chronic rhinosinusitis complicated by nasal polyps; severe, potentially fatal bronchospasm; and/or intolerance to aspirin and other nsaids. because cross-reactivity between aspirin and other nsaids has been reported in such aspirin-sensitive patients, diclofenac sodium extended-release tablets are contraindicated in patients with this form of aspirin sensitivity (see contraindications). when diclofenac sodium extended-release tablets are used in patients with preexisting asthma (without known aspirin sensitivity), monitor patients for changes in the signs and symptoms of asthma. serious skin reactions nsaids, including diclofenac, can cause serious skin adverse events such as exfoliative dermatitis, stevens-johnson syndrome (sjs), and toxic epidermal necrolysis (ten), which can be fatal. these serious events may occur without warning. inform patients about the signs and symptoms of serious skin reactions and to discontinue the use of diclofenac sodium extended-release tablets at the first appearance of skin rash or any other sign of hypersensitivity. diclofenac sodium extended-release tablets are contraindicated in patients with previous serious skin reactions to nsaids (see contraindications). drug reaction with eosinophilia and systemic symptoms (dress) drug reaction with eosinophilia and systemic symptoms (dress) has been reported in patients taking nsaids such as diclofenac sodium extended-release tablets. some of these events have been fatal or life-threatening. dress typically, although not exclusively, presents with fever, rash, lymphadenopathy, and/or facial swelling. other clinical manifestations may include hepatitis, nephritis, hematological abnormalities, myocarditis, or myositis. sometimes symptoms of dress may resemble an acute viral infection. eosinophilia is often present. because this disorder is variable in its presentation, other organ systems not noted here may be involved. it is important to note that early manifestations of hypersensitivity, such as fever or lymphadenopathy, may be present even though rash is not evident. if such signs or symptoms are present, discontinue diclofenac sodium extended-release tablets and evaluate the patient immediately. fetal toxicity premature closure of fetal ductus arteriosus: avoid use of nsaids, including diclofenac sodium extended-release tablets, in pregnant women at about 30 weeks gestation and later. nsaids including diclofenac sodium extended-release tablets, increase the risk of premature closure of the fetal ductus arteriosus at approximately this gestational age. oligohydramnios/neonatal renal impairment: use of nsaids, including diclofenac sodium extended-release tablets, at about 20 weeks gestation or later in pregnancy may cause fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment. these adverse outcomes are seen, on average, after days to weeks of treatment, although oligohydramnios has been infrequently reported as soon as 48 hours after nsaid initiation. oligohydramnios is often, but not always, reversible with treatment discontinuation. complications of prolonged oligohydramnios may, for example, include limb contractures and delayed lung maturation. in some postmarketing cases of impaired neonatal renal function, invasive procedures such as exchange transfusion or dialysis were required. if nsaid treatment is necessary between about 20 weeks and 30 weeks gestation, limit diclofenac sodium extended-release tablets use to the lowest effective dose and shortest duration possible. consider ultrasound monitoring of amniotic fluid if diclofenac sodium extended-release tablets treatment extends beyond 48 hours. discontinue diclofenac sodium extended-release tablets if oligohydramnios occurs and follow up according to clinical practice (see precautions; pregnancy). hematologic toxicity anemia has occurred in nsaid-treated patients. this may be due to occult or gross blood loss, fluid retention, or an incompletely described effect on erythropoiesis. if a patient treated with diclofenac sodium extended-release tablets has any signs or symptoms of anemia, monitor hemoglobin or hematocrit. nsaids, including diclofenac sodium extended-release tablets, may increase the risk of bleeding events. co-morbid conditions such as coagulation disorders, concomitant use of warfarin, other anticoagulants, antiplatelet agents (e.g., aspirin), serotonin reuptake inhibitors (ssris) and serotonin norepinephrine reuptake inhibitors (snris) may increase this risk. monitor these patients for signs of bleeding (see precautions; drug interactions). general diclofenac sodium extended-release tablets cannot be expected to substitute for corticosteroids or to treat corticosteroid insufficiency. abrupt discontinuation of corticosteroids may lead to disease exacerbation. patients on prolonged corticosteroid therapy should have their therapy tapered slowly if a decision is made to discontinue corticosteroids and the patient should be observed closely for any evidence of adverse effects, including adrenal insufficiency and exacerbation of symptoms of arthritis. the pharmacological activity of diclofenac sodium extended-release tablets in reducing fever and inflammation may diminish the utility of these diagnostic signs in detecting complications of presumed noninfectious, painful conditions. information for patients advise the patient to read the fda-approved patient labeling (medication guide) that accompanies each prescription dispensed. inform patients, families, or their caregivers of the following information before initiating therapy with diclofenac sodium extended-release tablets and periodically during the course of the ongoing therapy. cardiovascular thrombotic events advise patients to be alert for the symptoms of cardiovascular thrombotic events, including chest pain, shortness of breath, weakness, or slurring of speech, and to report any of these symptoms to their healthcare provider immediately (see warnings; cardiovascular thrombotic events). gastrointestinal bleeding, ulceration, and perforation advise patients to report symptoms of ulcerations and bleeding, including epigastric pain, dyspepsia, melena, and hematemesis to their healthcare provider. in the setting of concomitant use of low-dose aspirin for cardiac prophylaxis, inform patients of the increased risk for the signs and symptoms of gi bleeding (see warnings; gastrointestinal bleeding, ulceration, and perforation). hepatotoxicity inform patients of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, pruritus, jaundice, right upper quadrant tenderness, and “flu-like” symptoms). if these occur, instruct patients to stop diclofenac sodium extended-release tablets and seek immediate medical therapy (see warnings; hepatotoxicity). heart failure and edema advise patients to be alert for the symptoms of congestive heart failure, including shortness of breath, unexplained weight gain, or edema and to contact their healthcare provider if such symptoms occur (see warnings; heart failure and edema). anaphylactic reactions inform patients of the signs of an anaphylactic reaction (e.g., difficulty breathing, swelling of the face or throat). instruct patients to seek immediate emergency help if these occur (see warnings; anaphylactic reactions). serious skin reactions, including dress advise patients to stop diclofenac sodium extended-release tablets immediately if they develop any type of rash or fever and contact their healthcare provider as soon as possible (seewarnings; serious skin reactions). female fertility advise females of reproductive potential who desire pregnancy that nsaids, including diclofenac sodium extended-release tablets, may be associated with a reversible delay in ovulation (see precautions; carcinogenesis, mutagenesis, impairment of fertility). fetal toxicity inform pregnant women to avoid use of diclofenac sodium extended-release tablets and other nsaids starting at 30 weeks gestation because of the risk of the premature closure of the female ductus arteriosus. if treatment with diclofenac sodium extended-release tablets is needed for a pregnant woman between about 20 to 30 weeks gestation, advise her that she may need to be monitored for oligohydramnios, if treatment continues for longer than 48 hours (see warnings; fetal toxicity, precautions; pregnancy). avoid concomitant use of nsaids inform patients that the concomitant use of diclofenac sodium extended-release tablets with other nsaids or salicylates (e.g., diflunisal, salsalate) is not recommended due to the increased risk of gastrointestinal toxicity, and little or no increase in efficacy (see warnings: gastrointestinal bleeding, ulceration, and perforation and drug interactions). alert patients that nsaids may be present in “over- the-counter” medications for treatment of colds, fever, or insomnia. use of nsaids and low-dose aspirin inform patients not to use low-dose aspirin concomitantly with diclofenac sodium extended-release tablets until they talk to their healthcare provider (see precautions;drug interactions). masking of inflammation and fever the pharmacological activity of diclofenac sodium extended-release tablets in reducing inflammation, and possibly fever, may diminish the utility of diagnostic signs in detecting infection. laboratory monitoring because serious gi bleeding, hepatotoxicity, and renal injury can occur without warning symptoms or signs, consider monitoring patients on long-term nsaid treatment with a cbc and a chemistry profile periodically (see warnings;gastrointestinal bleeding,ulceration and perforation, and hepatotoxicity). drug interactions see table 2 for clinically significant drug interactions with diclofenac. table 2: clinically significant drug interactions with diclofenac drugs that interfere with hemostasis clinical impact: diclofenac and anticoagulants such as warfarin have a synergistic effect on bleeding. the concomitant use of diclofenac and anticoagulants have an increased risk of serious bleeding compared to the use of either drug alone. serotonin release by platelets plays an important role in hemostasis. case-control and cohort epidemiological studies showed that concomitant use of drugs that interfere with serotonin reuptake and an nsaid may potentiate the risk of bleeding more than an nsaid alone. intervention: monitor patients with concomitant use of diclofenac sodium extended-release tablets with anticoagulants (e.g., warfarin), antiplatelet agents (e.g., aspirin), selective serotonin reuptake inhibitors (ssris), and serotonin norepinephrine reuptake inhibitors (snris) for signs of bleeding (see warnings;hematological toxicity). aspirin clinical impact: controlled clinical studies showed that the concomitant use of nsaids and analgesic doses of aspirin does not produce any greater therapeutic effect than the use of nsaids alone. in a clinical study, the concomitant use of an nsaid and aspirin was associated with a significantly increased incidence of gi adverse reactions as compared to use of the nsaid alone (see warnings; gastrointestinal bleeding, ulceration, and perforation). intervention: concomitant use of diclofenac sodium extended-release tablets and analgesic doses of aspirin is not generally recommended because of the increased risk of bleeding (see warnings; hematological toxicity). diclofenac sodium extended-release tablets are not a substitute for low dose aspirin for cardiovascular protection. ace inhibitors, angiotensin receptor blockers, and beta-blockers clinical impact: nsaids may diminish the antihypertensive effect of angiotensin converting enzyme (ace) inhibitors, angiotensin receptor blockers (arbs), or beta-blockers (including propranolol). in patients who are elderly, volume-depleted (including those on diuretic therapy), or have renal impairment, co-administration of an nsaid with ace inhibitors or arbs may result in deterioration of renal function, including possible acute renal failure. these effects are usually reversible. intervention: during concomitant use of diclofenac sodium extended-release tablets and ace-inhibitors, arbs, or beta-blockers, monitor blood pressure to ensure that the desired blood pressure is obtained. during concomitant use of diclofenac sodium extended-release tablets and ace-inhibitors or arbs in patients who are elderly, volume-depleted, or have impaired renal function, monitor for signs of worsening renal function (see warnings; renal toxicity and hyperkalemia). when these drugs are administered concomitantly, patients should be adequately hydrated. assess renal function at the beginning of the concomitant treatment and periodically thereafter. diuretics clinical impact: clinical studies, as well as post-marketing observations, showed that nsaids reduced the natriuretic effect of loop diuretics (e.g., furosemide) and thiazide diuretics in some patients. this effect has been attributed to the nsaid inhibition of renal prostaglandin synthesis. intervention: during concomitant use of diclofenac sodium extended-release tablets with diuretics, observe patients for signs of worsening renal function, in addition to assuring diuretic efficacy including antihypertensive effects (see warnings; renal toxicity and hyperkalemia). digoxin clinical impact: the concomitant use of diclofenac with digoxin has been reported to increase the serum concentration and prolong the half-life of digoxin. intervention: during concomitant use of diclofenac sodium extended-release tablets and digoxin, monitor serum digoxin levels. lithium clinical impact: nsaids have produced elevations in plasma lithium levels and reductions in renal lithium clearance. the mean minimum lithium concentration increased 15%, and the renal clearance decreased by approximately 20%. this effect has been attributed to nsaid inhibition of renal prostaglandin synthesis. intervention: during concomitant use of diclofenac sodium extended-release tablets and lithium, monitor patients for signs of lithium toxicity. methotrexate clinical impact: concomitant use of nsaids and methotrexate may increase the risk for methotrexate (e.g., neutropenia, thrombocytopenia, renal dysfunction). intervention: during concomitant use of diclofenac sodium extended-release tablets and methotrexate, monitor patients for methotrexate toxicity. cyclosporine clinical impact: concomitant use of diclofenac sodium extended-release tablets and cyclosporine may increase cyclosporine’s nephrotoxicity. intervention: during concomitant use of diclofenac sodium extended-release tablets and cyclosporine, monitor patients for signs of worsening renal function. nsaids and salicylates clinical impact: concomitant use of diclofenac with other nsaids or salicylates (e.g., diflunisal, salsalate) increases the risk of gi toxicity, with little or no increase in efficacy (see warnings; gastrointestinal bleeding, ulceration, and perforation). intervention: the concomitant use of diclofenac with other nsaids or salicylates is not recommended. pemetrexed clinical impact: concomitant use of diclofenac sodium extended-release tablets and pemetrexed may increase the risk of pemetrexed-associated myelosuppression, renal, and gi toxicity (see the pemetrexed prescribing information). intervention: during concomitant use of diclofenac sodium extended-release tablets and pemetrexed, in patients with renal impairment whose creatinine clearance ranges from 45 to 79 ml/min, monitor for myelosuppression, renal, and gi toxicity. nsaids with short elimination half-lives (e.g., diclofenac, indomethacin) should be avoided for a period of two days before, the day of, and two days following administration of pemetrexed. in the absence of data regarding potential interaction between pemetrexed and nsaids with longer half-lives (e.g., meloxicam, nabumetone), patients taking these nsaids should interrupt dosing for at least five days before, the day of, and two days following pemetrexed administration. cyp2c9 inhibitors or inducers clinical impact: diclofenac is metabolized by cytochrome p450 enzymes, predominantly by cyp2c9. co-administration of diclofenac with cyp2c9 inhibitors (e.g., voriconazole) may enhance the exposure and toxicity of diclofenac whereas co-administration with cyp2c9 inducers (e.g., rifampin) may lead to compromised efficacy of diclofenac. intervention: a dosage adjustment may be warranted when diclofenac is administered with cyp2c9 inhibitors or inducers (see clinical pharmacology; pharmacokinetics). carcinogenesis, mutagenesis, impairment of fertility carcinogenesis long-term carcinogenicity studies in rats given diclofenac sodium up to 2 mg/kg/day (approximately 0.1 times the maximum recommended human dose [mrhd] of diclofenac sodium extended-release tablets, 200 mg/day, based on body surface area [bsa] comparison) have revealed no significant increase in tumor incidence. a 2-year carcinogenicity study conducted in mice employing diclofenac sodium at doses up to 0.3 mg/kg/day (approximately 0.007 times the mrhd based on bsa comparison) in males and 1 mg/kg/day (approximately 0.02 times the mrhd based on bsa comparison) in females did not reveal any oncogenic potential. mutagenesis diclofenac sodium did not show mutagenic activity in in vitro point mutation assays in mammalian (mouse lymphoma) and microbial (yeast, ames) test systems and was nonmutagenic in several mammalian in vitro and in vivo tests, including dominant lethal and male germinal epithelial chromosomal studies in mice, and nucleus anomaly and chromosomal aberration studies in chinese hamsters. impairment of fertility diclofenac sodium administered to male and female rats at 4 mg/kg/day (approximately 0.2 times the mrhd based on bsa comparison) did not affect fertility. based on the mechanism of action, the use of prostaglandin-mediated nsaids, including diclofenac sodium extended-release tablets, may delay or prevent rupture of ovarian follicles, which has been associated with reversible infertility in some women. published animal studies have shown that administration of prostaglandin synthesis inhibitors has the potential to disrupt prostaglandin-mediated follicular rupture required for ovulation. small studies in women treated with nsaids have also shown a reversible delay in ovulation. consider withdrawal of nsaids, including diclofenac sodium extended-release tablets, in women who have difficulties conceiving or who are undergoing investigation of infertility. pregnancy risk summary use of nsaids, including diclofenac sodium extended-release tablets, can cause premature closure of the fetal ductus arteriosus and fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment. because of these risks, limit dose and duration of diclofenac sodium extended-release tablets use between about 20 and 30 weeks of gestation, and avoid diclofenac sodium extended-release tablets use at about 30 weeks of gestation and later in pregnancy (see warnings; fetal toxicity). premature closure of fetal ductus arteriosus use of nsaids, including diclofenac sodium extended-release tablets, at about 30 weeks gestation or later in pregnancy increases the risk of premature closure of the fetal ductus arteriosus. oligohydramnios/neonatal renal impairment use of nsaids at about 20 weeks gestation or later in pregnancy has been associated with cases of fetal renal dysfunction leading to oligohydramnios, and in some cases, neonatal renal impairment. data from observational studies regarding other potential embryofetal risks of nsaid use in women in the first or second trimesters of pregnancy are inconclusive. in animal reproduction and developmental studies, animals demonstrated that diclofenac sodium administration during organogenesis did not produce teratogenicity despite the induction of maternal toxicity and fetal toxicity in mice at oral doses up to 20 mg/kg/day (approximately 0.5 times the maximum recommended human dose [mrhd] of diclofenac sodium extended-release tablets, 200 mg/day, based on body surface area (bsa) comparison), and in rats and rabbits at oral doses up to 10 mg/kg/day (approximately 0.5 and 1 times, respectively, the mrhd based on bsa comparison). in a study in which pregnant rats were orally administered 2 or 4 mg/kg diclofenac (0.1 and 0.2 times the mrhd based on bsa) from gestation day 15 through lactation day 21, significant maternal toxicity (peritonitis, mortality) was noted. these maternally toxic doses were associated with dystocia, prolonged gestation, reduced fetal weights and growth, and reduced fetal survival. diclofenac has been shown to cross the placental barrier in mice, rats, and humans. based on animal data, prostaglandins have been shown to have an important role in endometrial vascular permeability, blastocyst implantation, and decidualization. in animal studies, administration of prostaglandin synthesis inhibitors such as diclofenac, resulted in increased pre- and post-implantation loss. prostaglandins also have been shown to have an important role in fetal kidney development. in published animal studies, prostaglandin synthesis inhibitors have been reported to impair kidney development when administered at clinically relevant doses. the estimated background risk of major birth defects and miscarriage for the indicated population(s) is unknown. all pregnancies have a background risk of birth defect, loss, or other adverse outcomes. in the u.s. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. clinical considerations fetal/neonatal adverse reactions premature closure of fetal ductus arteriosus: avoid use of nsaids in women at about 30 weeks gestation and later in pregnancy, because nsaids, including diclofenac sodium extended-release tablets, can cause premature closure of the fetal ductus arteriosus (see warnings; fetal toxicity). oligohydramnios/neonatal renal impairment: if an nsaid is necessary at about 20 weeks gestation or later in pregnancy, limit the use to the lowest effective dose and shortest duration possible. if diclofenac sodium extended-release tablets treatment extends beyond 48 hours, consider monitoring with ultrasound for oligohydramnios. if oligohydramnios occurs, discontinue diclofenac sodium extended-release tablets and follow up according to clinical practice (see warnings; fetal toxicity). data human data premature closure of fetal ductus arteriosus: published literature reports that the use of nsaids at about 30 weeks of gestation and later in pregnancy may cause premature closure of the fetal ductus arteriosus. oligohydramnios/neonatal renal impairment: published studies and postmarketing reports describe maternal nsaid use at about 20 weeks gestation or later in pregnancy associated with fetal renal dysfunction leading to oligohydramnios, and in some cases, neonatal renal impairment. these adverse outcomes are seen, on average, after days to weeks of treatment, although oligohydramnios has been infrequently reported as soon as 48 hours after nsaid initiation. in many cases, but not all, the decrease in amniotic fluid was transient and reversible with cessation of the drug. there have been a limited number of case reports of maternal nsaid use and neonatal renal dysfunction without oligohydramnios, some of which were irreversible. some cases of neonatal renal dysfunction required treatment with invasive procedures, such as exchange transfusion or dialysis. methodological limitations of these postmarketing studies and reports include lack of a control group; limited information regarding dose, duration, and timing of drug exposure; and concomitant use of other medications. these limitations preclude establishing a reliable estimate of the risk of adverse fetal and neonatal outcomes with maternal nsaid use. because the published safety data on neonatal outcomes involved mostly preterm infants, the generalizability of certain reported risks to the full-term infant exposed to nsaids through maternal use is uncertain. animal data reproductive and developmental studies in animals demonstrated that diclofenac sodium administration during organogenesis did not produce teratogenicity despite the induction of maternal toxicity and fetal toxicity in mice at oral doses up to 20 mg/kg/day (approximately 0.5 times the maximum recommended human dose [mrhd] of diclofenac sodium extended-release tablets, 200 mg/day, based on body surface area (bsa) comparison), and in rats and rabbits at oral doses up to 10 mg/kg/day (approximately 0.5 and 1 times, respectively, the mrhd based on bsa comparison). in a study in which pregnant rats were orally administered 2 or 4 mg/kg diclofenac (0.1 and 0.2 times the mrhd based on bsa) from gestation day 15 through lactation day 21, significant maternal toxicity (peritonitis, mortality) was noted. these maternally toxic doses were associated with dystocia, prolonged gestation, reduced fetal weights and growth, and reduced fetal survival. diclofenac has been shown to cross the placental barrier in mice, rats, and humans. labor or delivery there are no studies on the effects of diclofenac sodium extended-release tablets during labor or delivery. in animal studies, nsaids, including diclofenac, inhibit prostaglandin synthesis, cause delayed parturition, and increase the incidence of stillbirth. nursing mothers risk summary based on available data, diclofenac may be present in human milk. the developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for diclofenac sodium extended-release tablets and any potential adverse effects on the breastfed infant from the diclofenac sodium extended-release tablets or from the underlying maternal condition. data one woman treated orally with a diclofenac salt, 150 mg/day, had a milk diclofenac level of 100 mcg/l, equivalent to an infant dose of about 0.03 mg/kg/day. diclofenac was not detectable in breast milk in 12 women using diclofenac (after either 100 mg/day orally for 7 days or a single 50 mg intramuscular dose administered in the immediate postpartum period). pediatric use safety and effectiveness in pediatric patients have not been established. geriatric use elderly patients, compared to younger patients, are at greater risk for nsaid-associated serious cardiovascular, gastrointestinal, and/or renal adverse reactions. if the anticipated benefit for the elderly patient outweighs these potential risks, start dosing at the low end of the dosing range, and monitor patients for adverse effects (see warnings; cardiovascular thrombotic events, gastrointestinal bleeding, ulceration, and perforation, hepatotoxicity, renal toxicity and hyperkalemia, precautions; laboratory monitoring). diclofenac is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function (see clinical pharmacology, adverse reactions).

elease tablets; diclofenac potassium immediate-release tablets] are not necessarily bioequivalent even if the milligram strength is the same.

atients are: gastrointestinal experiences including: abdominal pain, constipation, diarrhea, dyspepsia, flatulence, gross bleeding/perforation, heartburn, nausea, gi ulcers (gastric/duodenal) and vomiting. abnormal renal function, anemia, dizziness, edema, elevated liver enzymes, headaches, increased bleeding time, pruritus, rashes and tinnitus. additional adverse experiences reported occasionally include: body as a whole: fever, infection, sepsis cardiovascular system: congestive heart failure, hypertension, tachycardia, syncope digestive system: dry mouth, esophagitis, gastric/peptic ulcers, gastritis, gastrointestinal bleeding, glossitis, hematemesis, hepatitis, jaundice hemic and lymphatic system: ecchymosis, eosinophilia, leukopenia, melena, purpura, rectal bleeding, stomatitis, thrombocytopenia metabolic and nutritional: weight changes nervous system: anxiety, asthenia, confusion, depression, dream abnormalities, drowsiness, insomnia, malaise, nervousness, paresthesia, somnolence, tremors, vertigo respiratory system: asthma, dyspnea skin and appendages: alopecia, photosensitivity, sweating increased special senses: blurred vision urogenital system: cystitis, dysuria, hematuria, interstitial nephritis, oliguria/polyuria, proteinuria, renal failure other adverse reactions, which occur rarely are: body as a whole: anaphylactic reactions, appetite changes, death cardiovascular system: arrhythmia, hypotension, myocardial infarction, palpitations, vasculitis digestive system: colitis, eructation, fulminant hepatitis with and without jaundice, liver failure, liver necrosis, pancreatitis hemic and lymphatic system: agranulocytosis, hemolytic anemia, aplastic anemia, lymphadenopathy, pancytopenia metabolic and nutritional: hyperglycemia nervous system: convulsions, coma, hallucinations, meningitis respiratory system: respiratory depression, pneumonia skin and appendages: angioedema, toxic epidermal necrolysis, erythema multiforme, exfoliative dermatitis, stevens-johnson syndrome, urticaria special senses: conjunctivitis, hearing impairment to report suspected adverse reactions, contact oceanside pharmaceuticals at 1-800-321-4576 or fda at 1-800-fda-1088 or www.fda.gov/medwatch.

absorbed dose is systemically available (see table 1). when diclofenac sodium extended-release tablets are taken with food, there is a delay of 1 to 2 hours in the tmax and a two-fold increase in cmax values. the extent of absorption of diclofenac, however, is not significantly affected by food intake. table 1. pharmacokinetic parameters for diclofenac pk parameter normal healthy adults (18 to 48 yrs.) mean coefficient of variation (%) absolute bioavailability (%) [n=7] 55 40 tmax (hr) [n = 12] 5.3 28 oral clearance (cl/f; ml/min) [n = 12] 895 56 renal clearance (% unchanged drug in urine) [n = 7] <1 — apparent volume of distribution (v/f; l/kg) [n = 56] 1.4 58 terminal half-life (hr) [n = 56] 2.3 48 distribution the apparent volume of distribution (v/f) of diclofenac sodium is 1.4 l/kg. diclofenac is more than 99% bound to human serum proteins, primarily to albumin. serum protein binding is constant over the concentration range (0.15 to 105 mcg/ml) achieved with recommended doses. diclofenac diffuses into and out of the synovial fluid. diffusion into the joint occurs when plasma levels are higher than those in the synovial fluid, after which the process reverses and synovial fluid levels are higher than plasma levels. it is not known whether diffusion into the joint plays a role in the effectiveness of diclofenac. elimination metabolism five diclofenac metabolites have been identified in human plasma and urine. the metabolites include 4'-hydroxy-, 5-hydroxy-, 3'-hydroxy-, 4',5-dihydroxy- and 3'-hydroxy-4'-methoxy-diclofenac. the major diclofenac metabolite, 4'-hydroxy-diclofenac, has very weak pharmacologic activity. the formation of 4'-hydroxy diclofenac is primarily mediated by cpy2c9. both diclofenac and its oxidative metabolites undergo glucuronidation or sulfation followed by biliary excretion. acylglucuronidation mediated by ugt2b7 and oxidation mediated by cpy2c8 may also play a role in diclofenac metabolism. cyp3a4 is responsible for the formation of minor metabolites, 5-hydroxy- and 3'-hydroxy-diclofenac. in patients with renal dysfunction, peak concentrations of metabolites 4'-hydroxy- and 5-hydroxy-diclofenac were approximately 50% and 4% of the parent compound after single oral dosing compared to 27% and 1% in normal healthy subjects. excretion diclofenac is eliminated through metabolism and subsequent urinary and biliary excretion of the glucuronide and the sulfate conjugates of the metabolites. little or no free unchanged diclofenac is excreted in the urine. approximately 65% of the dose is excreted in the urine and approximately 35% in the bile as conjugates of unchanged diclofenac plus metabolites. because renal elimination is not a significant pathway of elimination for unchanged diclofenac, dosing adjustment in patients with mild to moderate renal dysfunction is not necessary. the terminal half-life of unchanged diclofenac is approximately 2 hours. special populations pediatric: the pharmacokinetics of diclofenac sodium extended-release tablets have not been investigated in pediatric patients. race: pharmacokinetic differences due to race have not been identified. hepatic insufficiency: hepatic metabolism accounts for almost 100% of diclofenac sodium extended-release tablets elimination, so patients with hepatic disease may require reduced doses of diclofenac sodium extended-release tablets compared to patients with normal hepatic function. renal insufficiency: diclofenac pharmacokinetics has been investigated in subjects with renal insufficiency. no differences in the pharmacokinetics of diclofenac have been detected in studies of patients with renal impairment. in patients with renal impairment (inulin clearance 60 to 90, 30 to 60, and <30 ml/min; n=6 in each group), auc values and elimination rate were comparable to those in healthy subjects. drug interactions studies voriconazole: when co-administered with voriconazole (inhibitor of cyp2c9, 2c19, and 3a4 enzyme), the cmax and auc of diclofenac increased by 114% and 78%, respectively (see precautions; drug interactions). aspirin: when nsaids were administered with aspirin, the protein binding of nsaids were reduced, although the clearance of free nsaid was not altered. the clinical significance of this interaction is not known. see table 2 for clinically significant drug interactions of nsaids with aspirin (see precautions; drug interactions).