DICLOFENAC (Page 3 of 7)

5.10 Premature Closure of Fetal Ductus Arteriosus

Diclofenac may cause premature closure of the fetal ductus arteriosus. Avoid use of NSAIDs, including Diclofenac Capsules, in pregnant women starting at 30 weeks of gestation (third trimester) [see Use in Specific Populations (8.1) ].

5.11 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 Capsules has any signs or symptoms of anemia, monitor hemoglobin or hematocrit.

NSAIDs, including Diclofenac Capsules, 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 Drug Interactions (7) ].

5.12 Masking of Inflammation and Fever

The pharmacological activity of Diclofenac Capsules in reducing inflammation, and possibly fever, may diminish the utility of diagnostic signs in detecting infections.

5.13 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 and Precautions (5.2, 5.3, 5.6)].

6 ADVERSE REACTIONS

The following adverse reactions are discussed in greater detail in other sections of the labeling:

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.

Adverse Reactions in Patients with Acute Pain

Two-hundred sixteen (216) patients received Diclofenac Capsules in the completed, 48-hour, double-blind, placebo-controlled, clinical trial of acute pain following bunionectomy. The most frequent adverse reactions in this study are summarized in Table 1.

Table 1 Summary of Adverse Reactions (≥2% in Diclofenac Capsules 18 mg or 35 mg group) – Phase 3 Study in Patients With Postsurgical Pain
Adverse Reactions Diclofenac Capsules 18 mg or 35 mg three times daily *N = 216 Placebo *N = 106
*
One tablet of hydrocodone/acetaminophen 10 mg/325 mg was permitted every 4 to 6 hours as rescue medication for pain management. There was a greater use of concomitant opioid rescue medication in placebo-treated patients than in Diclofenac Capsules-treated patients. About 82% of patients in the Diclofenac Capsules 35 mg group, 85% of the patients in the Diclofenac Capsules 18 mg group, and 97% of patients in the placebo group took rescue medication for pain management during the study.
Edema 33% 32%
Nausea 27% 37%
Headache 13% 15%
Dizziness 10% 16%
Vomiting 9% 12%
Constipation 8% 4%
Pruritus 7% 6%
Flatulence 3% 2%
Pain in Extremity 3% 1%
Dyspepsia 2% 1%

Adverse Reactions in Patients with Osteoarthritis Pain

Two-hundred two (202) patients received Diclofenac Capsules in the completed, 12-week, double-blind, placebo-controlled, clinical trial of osteoarthritis pain of the knee or hip. The most frequent adverse reactions in this study are summarized in Table 2.

Table 2 Summary of Adverse Reactions (≥2%) – 12-week Phase 3 Study in Patients With Osteoarthritis Pain *
Adverse Reactions Diclofenac Capsules 35 mg N=202 Placebo N=103
*
Adverse reactions that occurred in >2% of patients treated with Diclofenac Capsules and occurred more frequently than in patients treated with placebo
Nausea 7% 2%
Diarrhea 6% 3%
Headache 4% 3%
Abdominal Pain Upper 3% 1%
Sinusitis 3% 1%
Vomiting 3% 1%
Alanine Aminotransferase Increased 2% 0
Blood Creatinine Increased 2% 0
Dyspepsia 2% 1%
Flatulence 2% 0
Hypertension 2% 1%

Six-hundred one (601) patients received Diclofenac Capsules 35 mg either twice or three times daily in a 52-week, open-label, clinical trial in osteoarthritis pain of the knee or hip. Of those, 360 (60%) patients completed the trial. The most frequent adverse reactions in this study are summarized in Table 3.

Table 3 Summary of Adverse Reactions (≥2%) – 52-week Open-label Study in Patients with Osteoarthritis Pain
Adverse Reactions Diclofenac Capsules 35 mg N=601
Upper respiratory tract infection 8%
Headache 8%
Urinary tract infection 7%
Diarrhea 6%
Nasopharyngitis 6%
Nausea 6%
Constipation 5%
Sinusitis 5%
Osteoarthritis 5%
Cough 4%
Alanine aminotransferase increased 4%
Back pain 3%
Dyspepsia 3%
Procedural pain 3%
Bronchitis 3%
Hypertension 3%
Abdominal pain upper 3%
Influenza 3%
Arthralgia 3%
Contusion 3%
Vomiting 3%
Abdominal discomfort 2%
Aspartate aminotransferase increased 2%
Dizziness 2%
Fall 2%
Abdominal pain 2%

Adverse reactions reported for diclofenac and other NSAIDs:

In patients taking other NSAIDs, the most frequently reported adverse reactions occurring in approximately 1%-10% of patients 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 reactions 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

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