Diclofast спрей сирия инструкция по применению

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Торговое название

ДиклоФлекс

Международное непатентованное название

Диклофенак

Лекарственная форма

Спрей для наружного применения, 4 %, 12.5 г или 25 г

Состав

1 г спрея содержит

активное вещество: натрия диклофенак — 40 мг,

вспомогательные вещества: пропиленгликоль, спирт изопропиловый, лецитин соевый 76 %, этанол, натрия дигидрофосфат дигидрат, динатрия фосфат додекагидрат, динатрия эдетат, масло мятное, аскорбилпальмитат, вода очищенная, кислота хлороводородная, натрия гидроксид.

Описание

Прозрачный раствор золотисто — желтого цвета с запахом спирта изопропилового и мяты перечной.

Фармакотерапевтическая группа

Нестероидные противовоспалительные препараты для местного применения.

Код АТХ М02АА15

Фармакологические свойства

Фармакокинетика

После распыления на кожу 1.5 г препарата, наблюдается быстрое начало абсорбции диклофенака. Через 30 минут после нанесения на кожу, плазменные уровни достигают значений около 1 нг/мл. Максимальные уровни, составляющие около 3 нг/мл, наблюдаются приблизительно через 24 часа. Системные концентрации диклофенака приблизительно в 50 раз ниже концентраций, которые достигаются после перорального приема эквивалентных количеств диклофенака. Предполагается, что системные плазменные уровни не влияют на эффективность ДиклоФлекса.

Диклофенак интенсивно связывается белками плазмы (приблизительно 99 %).

Фармакодинамика

ДиклоФлекс – нестероидное противовоспалительное средство (НПВС). Оказывает выраженное противовоспалительное, обезболивающее и умеренное жаропонижающее действие.

Основным механизмом действия диклофенака является торможение биосинтеза простагландинов, играющих важную роль в генезе воспаления, боли и лихорадки.

ДиклоФлекс используется для устранения болевого синдрома и уменьшения отечности, связанной с воспалительным процессом.

Показания к применению

— локальное симптоматическое облегчение легкой и умеренной боли и воспаления сухожилий, связок, мышц и суставов, обусловленных травмой.

Способ применения и дозы

Только для нанесения на кожу.

После распыления препарат приобретает гелеобразную консистенцию. При каждом нажатии распылителя выделяется около 0.2 г спрея, содержащего 8 мг натрия диклофенака.

Взрослые

Рекомендованная доза для нанесения на кожу составляет 1.0 — 3.0 г спрея в сутки.

Однократная доза препарата не должна превышать 1.0 г спрея (содержащего 40 мг натрия диклофенака), что составляет 5 нажатий распылителя. Максимальная суточная доза не должна превышать 3.0 г спрея (содержащего 120 мг натрия диклофенака), что составляет 15 нажатий распылителя.

Следует наносить достаточное количество ДиклоФлекс на кожу пораженного участка. В зависимости от размера обрабатываемого участка, препарат необходимо применять 3 раза в сутки 4-5 нажатиями распылителя, через регулярные интервалы времени.

ДиклоФлекс следует осторожно втирать в кожу, после чего необходимо тщательно вымыть руки, кроме случаев, когда руки являются обрабатываемым участком. После нанесения на кожу, препарат должен высохнуть в течение нескольких минут.

Лечение препаратом может быть прекращено при уменьшении симптомов (боли и отека). Лечение не должно продолжаться свыше 7 дней без консультации врача. Следует проконсультироваться с врачом, если улучшение не наступает после 3 дней лечения.

Пожилые пациенты

Специальной корректировки дозы не требуется.

Дети

Опыта применения у детей нет, поэтому, ДиклоФлекс не рекомендуется для применения у детей до 15 лет.

Пациенты c печеночной или почечной недостаточностью

У пациентов с нарушениями функций почек и печени препарат следует применять с осторожностью.

Побочные действия

Часто

— реакции в месте нанесения, зуд и крапивница, сухость, гиперемия, чувство жжения, контактный дерматит

Нечасто

— боль в животе, диспепсия, нарушения пищеварительного тракта

— нарушение функции почек

Редко

— астма

Очень редко

— генерализованная кожная сыпь и реакции гиперчувствительности, такие как ангионевротический отек и реакции фоточувствительности.

Противопоказания

— повышенная чувствительность к диклофенаку или к любому из

вспомогательных веществ лекарственного препарата

— повышенная чувствительность к ацетилсалициловой кислоте или другим

нестероидным противовоспалительным препаратам

— бронхиальная астма, крапивница или ринит, спровоцированные приемом

ацетилсалициловой кислоты или других нестероидных

противовоспалительных препаратов

— период беременности и лактации

— нанесение на область молочных желез

— детский и подростковый возраст до 15 лет.

Лекарственные взаимодействия

Системная биодоступность диклофенака из данной лекарственной формы очень низкая. Следовательно, риск взаимодействия с другими лекарственными препаратами невелик.

Одновременный прием ацетилсалициловой кислоты или других НПВС может привести к увеличению частоты побочных реакций.

Особые указания

Не следует допускать попадания препарата в глаза и на слизистые оболочки. ДиклоФлекс следует наносить только на неповрежденную кожу, избегая попадания на открытые раны или пораженные участки кожи. Необходимо избегать избыточного воздействия солнечного света во время лечения препаратом для уменьшения риска фоточувствительности.

При возникновении сыпи, лечение следует прекратить.

ДиклоФлекс не применяют с окклюзионной повязкой.

Препарат нельзя наносить на обширные участки кожи (более 600 квадратных сантиметров поверхности тела) и использовать в течение продолжительного периода времени (более четырех недель) из-за возможности развития системных побочных эффектов (гиперчувствительности, астматических реакций или побочных эффектов со стороны почек). У пациентов, страдающих от бронхиальной астмы, или имеющих ее в анамнезе, приступ бронхоспазма может быть ускорен.

ДиклоФлекс следует применять с осторожностью у больных с пептической язвой, печеночной или почечной недостаточностью, или геморрагическим диатезом, а также воспалительными заболеваниями кишечника.

Пропиленгликоль, содержащийся в препарате ДиклоФлекс, может вызывать кожное раздражение, масло мяты перечной может вызвать аллергические реакции.

Для снижения риска развития нежелательных явлений, следует использовать минимальную эффективную дозу при минимально коротком курсе лечения.

Особенности влияния лекарственного средства на способность управлять транспортом и другими потенциально опасными механизмами

ДиклоФлекс оказывал незначительное влияние на способность управлять автомобилем и пользоваться механизмами. Пациенты, которые страдают головокружением или другими нарушениями со стороны центральной нервной системы во время приема НПВС, должны воздерживаться от управления транспортом и пользования механизмами, но такие симптомы чрезвычайно маловероятны при использовании препаратов для наружного применения.

Передозировка

Во время применения препарата в рекомендуемой дозе риск передозировки отсутствует. При случайном пероральном введении препарата следует провести симптоматическое лечение. Специфического антидота нет.

Форма выпуска и упаковка

По 12.5 г или 25 г препарата во флаконах из темного стекла (тип III Евр.Фарм.) с номинальным объемом наполнения 15 мл или 30 мл, оснащенных распылителем и защитным колпачком из пластиковых материалов.

По 1 флакону вместе с инструкцией по медицинскому применению лекарственного средства на государственном и русском языках помещают в картонную коробку.

Условия хранения

Хранить при температуре не выше 25º С, в оригинальной упаковке.

Хранить в недоступном для детей месте!

Срок хранения

3 года

После первого вскрытия упаковки — 6 месяцев.

Не использовать после окончания срока годности, указанного на упаковке.

Условия отпуска из аптек

Без рецепта

Производитель

Фарбил Вальтроп ГмбХ,

Им Вирриген 25, 45731, Вальтроп, Германия

Владелец регистрационного удостоверения

ФармаСвисс Чешская Республика с.р.о., Чешская Республика.

Джанковкова 1569/2с, 17000, Прага 7, Чешская Республика

Телефон: +386 (0) 1 236 47 12, факс: +386 (0) 1 236 47 05

Адрес организации, принимающей на территории Республики Казахстан претензии от потребителей по качеству продукции (товара):

ТОО «Adalan», Республика Казахстан, 050057, г. Алматы, ул. Тимирязева, 42, павильон 23, офис 202. Тел. + 7(727) 269-54-59.

Е-mail: reg@adalan.kz. 

WARNINGS

Included as part of the PRECAUTIONS section.

PRECAUTIONS

Cardiovascular Thrombotic Events

Clinical trials of several COX-2 selective and nonselective NSAIDs of up to three years duration have shown an increased risk of serious cardiovascular (CV) thrombotic events, including myocardial infarction (MI), and stroke, which can be fatal. Based on available data, it is unclear that the risk for CV thrombotic events is similar for all NSAIDs. The relative increase in serious CV thrombotic events over baseline conferred by NSAID use appears to be similar in those with and without known CV disease or risk factors for CV disease. However, patients with known CV disease or risk factors had a higher absolute incidence of excess serious CV thrombotic events, due to their increased baseline rate. Some observational studies found that this increased risk of serious CV thrombotic events began as early as the first weeks of treatment. The increase in CV thrombotic risk has been observed most consistently at higher doses.

To minimize 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.

Status Post Coronary Artery Bypass Graft (CABG) Surgery

Two large, controlled, clinical trials of a COX-2 selective NSAID for the treatment of pain in the first 10-14 days following CABG surgery found an increased incidence of myocardial infarction and stroke. NSAIDs are contraindicated in the setting of CABG.

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 Diclofast in patients with a recent MI unless the benefits are expected to outweigh the risk of recurrent CV thrombotic events. If Diclofast is used in patients with a recent MI, monitor patients for signs of cardiac ischemia.

Gastrointestinal Bleeding, Ulceration, And Perforation

NSAIDs, including diclofenac, 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 NSAID 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 used 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 dosage 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 Diclofast 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.

Hepatotoxicity

In clinical trials of oral diclofenac containing products, meaningful elevations (i.e., more than 3 times the ULN) of AST (SGOT) occurred 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 for 2 — 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 3,700 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 to 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 oral 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 NSAID 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 oral 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.), Diclofast 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 Diclofast immediately, and perform a clinical evaluation of the patient.

To minimize the potential risk for an adverse liver-related event in patients treated with Diclofast, use the lowest effective dose for the shortest duration possible. Exercise caution when prescribing Diclofast with concomitant drugs that are known to be potentially hepatotoxic (e.g., acetaminophen, antibiotics, antiepileptics).

Hypertension

NSAIDs, including Diclofast, 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, thiazide diuretics, or loop diuretics may have impaired response to these therapies when taking NSAIDs.

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 hospitalizations 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]).

Avoid the use of Diclofast in patients with severe heart failure unless the benefits are expected to outweigh the risk of worsening heart failure. If Diclofast is 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 Diclofast in patients with advanced renal disease. The renal effects of Diclofast may hasten the progression of renal dysfunction in patients with preexisting renal disease.

Correct volume status in dehydrated or hypovolemic patients prior to initiating Diclofast. Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia during use of Diclofast. Avoid the use of Diclofast in patients with advanced renal disease unless the benefits are expected to outweigh the risk of worsening renal function. If Diclofast is 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.

Seek emergency help if an anaphylactic reaction occurs.

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, Diclofast is contraindicated in patients with this form of aspirin sensitivity. When Diclofast is 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 reactions 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 Diclofast at the first appearance of skin rash or any other sign of hypersensitivity. Diclofast is contraindicated in patients with previous serious skin reactions to NSAIDs.

Do not apply Diclofast to open skin wounds, infections, inflammations, or exfoliative dermatitis, as it may affect absorption and tolerability of the drug.

Premature Closure Of Fetal Ductus Arteriosus

Diclofenac may cause premature closure of the fetal ductus arteriosus. Avoid use of NSAIDs, including Diclofast, in pregnant women starting at 30 weeks of gestation (third trimester).

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

NSAIDs, including Diclofast, may increase the risk of bleeding events. Co-morbid conditions such as coagulation disorders or 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.

Masking Of Inflammation And Fever

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

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.

Sun Exposure

Instruct patients to avoid exposure to natural or artificial sunlight on treated knee(s) because studies in animals indicated topical diclofenac treatment resulted in an earlier onset of ultraviolet light-induced skin tumors. The potential effects of Diclofast on skin response to ultraviolet damage in humans are not known.

Eye Exposure

Avoid contact of Diclofast with eyes and mucosa. Advise patients that if eye contact occurs, immediately wash out the eye with water or saline and consult a physician if irritation persists for more than an hour.

Oral Nonsteroidal Anti-Inflammatory Drugs

Concomitant use of oral NSAIDs with Diclofast 1.5% resulted in a higher rate of rectal hemorrhage, more frequent abnormal creatinine, urea and hemoglobin. Therefore, do not use combination therapy with Diclofast and an oral NSAID unless the benefit outweighs the risk and conduct periodic laboratory evaluations.

Patient Counseling Information

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 Diclofast and periodically during the course of 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 health care provider immediately.

Gastrointestinal Bleeding, Ulceration, And Perforation

Advise patients to report symptoms of ulceration and bleeding, including epigastric pain, dyspepsia, melena, and hematemesis to their health care provider. In the setting of concomitant use of low-dose aspirin for cardiac prophylaxis, inform patients of the increased risk for and the signs and symptoms of GI bleeding.

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 Diclofast and seek immediate medical therapy.

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.

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.

Serious Skin Reactions

Advise patients to stop Diclofast immediately if they develop any type of rash and contact their health care provider as soon as possible.

Female Fertility

Advise females of reproductive potential who desire pregnancy that NSAIDs, including Diclofast, may be associated with a reversible delay in ovulation

Fetal Toxicity

Inform pregnant women to avoid use of Diclofast and other NSAIDs starting at 30 weeks gestation because of the risk of the premature closing of the fetal ductus arteriosus.

Avoid Concomitant Use Of NSAIDs

Inform patients that the concomitant use of Diclofast 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. 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 Diclofast until they talk to their healthcare provider.

Eye Exposure

Instruct patients to avoid contact of Diclofast with the eyes and mucosa. Advise patients that if eye contact occurs, immediately wash out the eye with water or saline and consult a physician if irritation persists for more than an hour.

Prevention Of Secondary Exposure

Instruct patients to avoid skin-to-skin contact between other people and the knee(s) to which Diclofast was applied until the knee(s) is completely dry.

Special Application Instructions

Instruct patients not to apply Diclofast to open skin wounds, infections, inflammations, or exfoliative dermatitis, as it may affect absorption and reduce tolerability of the drug.

Instruct patients to wait until the area treated with Diclofast is completely dry before applying sunscreen, insect repellant, lotion, moisturizer, cosmetics, or other topical medication.

Instruct patients to minimize or avoid exposure of treated knee(s) to natural or artificial sunlight.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

Carcinogenesis

Carcinogenicity studies in mice and rats administered diclofenac sodium as a dietary constituent for 2 years resulted in no significant increases in tumor incidence at doses up to 2 mg/kg/day approximately 0.85 and 1.7 times, respectively, the maximum recommended human topical dose of Diclofast (based on apparent bioavailability and body surface area comparison).

In a dermal carcinogenicity study conducted in albino mice, daily topical applications of diclofenac sodium for two years at concentrations up to 0.035% diclofenac sodium (a 57-fold lower diclofenac sodium concentration than present in Diclofast) did not increase neoplasm incidence.

In a photococarcinogenicity study conducted in hairless mice, topical application of diclofenac sodium at doses up to 0.035% diclofenac sodium (a 57-fold lower diclofenac sodium concentration than present in Diclofast) resulted in an earlier median time of onset of tumors.

Mutagenesis

Diclofenac was not mutagenic or clastogenic in a battery of genotoxicity tests that included the bacterial reverse mutation assay, in vitro mouse lymphoma point mutation assay, chromosomal aberration studies in Chinese hamster ovarian cells in vitro, and in vivo rat chromosomal aberration assay of bone marrow cells.

Impairment Of Fertility

Fertility studies have not been conducted with Diclofast. Diclofenac sodium administered to male and female rats at doses up to 4 mg/kg/day (approximately 3.4 times the MRHD of Diclofast based on apparent bioavailability and body surface area comparison) did not affect fertility. Studies conducted in rats found no effect of dermally applied DMSO on fertility, reproductive performance, or offspring performance.

Use In Specific Populations

Pregnancy

Pregnancy Category C prior to 30 weeks gestation; Category D starting 30 weeks gestation

Risk Summary

Use of NSAIDs, including Diclofast, during the third trimester of pregnancy increases the risk of premature closure of the fetal ductus arteriosus. Avoid use of NSAIDs, including Diclofast, in pregnant women starting at 30 weeks of gestation (third trimester).

There are no adequate and well-controlled studies of Diclofast in pregnant women. Data from observational studies regarding potential embryofetal risks of NSAID use in women in the first or second trimesters of pregnancy are inconclusive. In the general U.S. population, all clinically recognized pregnancies, regardless of drug exposure, have a background rate of 2-4% for major malformations, and 15-20% for pregnancy loss. Published reproductive and developmental studies of dimethyl sulfoxide (DMSO, the solvent used in Diclofast) are equivocal as to potential teratogenicity. In animal reproduction studies, no evidence of teratogenicity was observed in mice, rats, or rabbits given diclofenac during the period of organogenesis at doses up to approximately 0.6, 0.6, and 1.3 times, respectively, the maximum recommended human dose (MRHD) of Diclofast, despite the presence of maternal and fetal toxicity at these doses. 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.

Clinical Considerations

Labor or Delivery

There are no studies on the effects of Diclofast during labor or delivery. In animal studies, NSAIDs, including diclofenac inhibit prostaglandin synthesis, cause delayed parturition, and increase the incidence of stillbirth.

Data

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 0.6 times the maximum recommended human dose [MRHD] of Diclofast, 162 mg/day, based on body surface area (BSA) comparison), and in rats and rabbits at oral doses up to 10 mg/kg/day (approximately 0.6 and 1.3-times, respectively, the MRHD based on BSA comparison). Published reproductive and developmental studies of dimethyl sulfoxide (DMSO, the solvent used in Diclofast) are equivocal as to potential teratogenicity. In rats, maternally toxic doses of diclofenac were associated with dystocia, prolonged gestation, reduced fetal weights and growth, and reduced fetal survival.

Lactation

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 CATAFLAM and any potential adverse effects on the breastfed infant from the CATAFLAM 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).

Females And Males Of Reproductive Potential

Infertility

Females

Based on the mechanism of action, the use of prostaglandin-mediated NSAIDs, including Diclofast, 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 Diclofast, in women who have difficulties conceiving or who are undergoing investigation of infertility.

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.

Of the 911 patients treated with Diclofast 1.5% in seven controlled, Phase 3 clinical trials, 444 subjects were 65 years of age and over. There was no age-related difference in the incidence of adverse events. Of the 793 patients treated with Diclofast 1.5% in one open-labeled safety trial, 334 subjects were 65 years of age and over including 107 subjects 75 and over. There was no difference in the incidence of adverse events with long-term exposure to Diclofast 1.5% for this elderly population.