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Diclofenac sodium 25 mg tabs every 8 hours up to 4 times per day until it is fully absorbed, and then increase to twice daily. This could include use of a topical or liquid formulation, as well intravaginal application by self-medicating or with a partner. Use of transdermal delivery system, such as naltrexone patches, might also be considered. Intravenous therapy There is no known evidence supporting the routine use of intravaginal nonsteroidal anti-inflammatory drugs, such as ibuprofen, in patients who are on glucocorticoid therapy. However, the benefits of intravaginal corticosteroids are limited to individuals at very high risk. When intravaginal corticosteroids are needed in such individuals (eg, patients with rheumatoid arthritis or psoriatic arthritis), they are usually considered in combination with a short-acting antiinflammatory, such as methotrexate. Other types of treatment Treatment of osteoarthritis with an NSAID alone is not recommended. Although data are lacking, one clinical trial showed that use of an NSAID along with NSAIDs reduced pain as measured by the visual analog scale when compared with an NSAID therapy alone; however, the results of clinical trial were overshadowed by the risk of adverse events. Treatment of osteoarthritis with an NSAID in combination other therapy (eg, NSAIDS/corticosteroids) has been shown to be beneficial for some patients with a joint disorder. However, in the clinical trial, it is not known whether the use of NSAIDS/corticosteroids was beneficial because a synergistic effect with glucocorticoid therapy or because it was an additive effect with other NSAIDs. Some information was obtained from a clinical trial involving glucocorticoids and NSAIDs, where the combined therapy was not used, in patients who were treated with corticosteroids for symptoms associated osteoarthritis diclofenac potassium 50 mg tabs or joint inflammation. Some of this information may be useful in considering an NSAID therapy for a patient with osteoarthritis. Information for prescribers Patients should be counseled that a treatment choice with glucocorticoids should be discussed in conjunction with a detailed risk-benefit assessment. Patients will need to be monitored carefully for any signs or symptoms that indicate systemic absorption of exogenous glucocorticoids. The risks NSAID therapy for osteoarthritis should be discussed with patients, particularly in those patients with a risk of gastrointestinal malabsorption or liver problems. Patients should be counseled about gastrointestinal adverse effects and treatment implications about taking glucocorticoid at high dosages. Discontinuation of NSAID therapy should be carefully guided by history, physical exam, and the presence or absence of any the diclofenac sodium 25 mg tabs coexisting conditions noted above. Patients should be advised that glucocorticoid therapy should be continued for at least 3 months and that chronic use is generally associated with more adverse effects than do intermittent therapy with NSAIDs. The American College drug use in canada vs us of Rheumatology (ACR) clinical practice guidelines for the management of rheumatoid arthritis recommend that patients who meet the criteria for treatment with bisphosphonates be offered intra-articular glucocorticoid injections, but not intratracheal intra-articular therapy with glucocorticoids.4 Patients should be counseled about the availability of anti-inflammatory drugs available for intra-articular treatment, including hydroxychloroquine, celecoxib, methotrexate, nizatidine, and etoricoxib.5 Patients should be counseled that glucocorticoids are contraindicated in patients with a history of Guillain-Barré syndrome or in those with abnormal liver function test results. There are no data on the use of glucocorticoids in patients who take aspirin or warfarin, and no controlled clinical trials have been conducted in this population. Gastrointestinal adverse effects of glucocorticoids have been described in the literature.7-9 Symptoms generally associated with gastrointestinal effects, such as pain, nausea, and vomiting, are similar to those that may be associated with drug toxicity. Therefore, patients are expected to have these symptoms, which may be aggravated by the use of glucocorticoids, when using glucocorticoid therapy. Patients should be advised of this possibility. Drug safety Because of a well-known association between glucocorticoids and gastrointestinal bleeding thromboembolic diseases [See Adverse Reactions (6.7)], the effectiveness of glucocorticoid therapy was questioned for the treatment of osteoarthritis hip,6,14,15 and there is a long-standing concern regarding their safety in patients with a family history of thrombosis.

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