Lidocaine 4.5%, Diclofenac 1%

INDICATION AND USAGE Diclona™ is indicated for relief of pain associated with arthritis, backache, cramps, discomfort, neckache, soreness, sprains, strains. It should be applied only to intact skin. Sun avoidance is indicated during therapy.

DOSAGE AND ADMINISTRATION Apply Diclona™ to intact skin to cover the most painful area. Clean and dry the affected area. Apply product directly to your skin, up to 4 times daily. Clothing may be worn over the area of application. If irritation or a burning sensation occurs during application, wash the product off your skin and do not reapply until the irritation subsides. When Diclona™ is used concomitantly with other products containing local anesthetic agents, the amount absorbed from all formulations must be considered.

WARNINGS Medicines intended to be applied to the skin should not be swallowed. Diclona™ is flammable . Keep away from open flame. You should never heat, microwave, or add the medicine to hot water. Risk of Methemoglobinemia Cases of methemoglobinemia have been reported in association with lidocaine use. Although all patients are at risk for methemoglobinemia, patients with glucose-6-phosphate dehydrogenase deficiency, congenital or idiopathic methemoglobinemia, cardiac or pulmonary compromise, infants under 6 months of age, and concurrent exposure to oxidizing agents or their metabolites are more susceptible to developing the condition. If lidocaine must be used in these patients, close monitoring for symptoms and signs of methemoglobinemia is recommended. Signs of methemoglobinemia may occur immediately or may be delayed some hours after exposure and are characterized by a cyanotic skin discoloration and/or abnormal coloration of the blood. Methemoglobin levels may continue to rise; therefore, immediate treatment is required to avert more serious central nervous system and cardiovascular adverse effects, including seizures, coma, arrhythmias, and death. Risk of Serious Cardiovascular Events Cardiovascular Thrombotic Events Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in treatment and may increase with duration of use. Fetal Toxicity Avoid use of NSAIDs in pregnant women at about 30 weeks gestation and later. NSAIDs increase the risk of premature closure of the fetal ductus arteriosus at approximately this gestational age. Use of NSAIDs at about 20 weeks gestation or later in pregnancy may cause fetal renal dysfunction leading to oligohydramnios and, in some case, neonatal renal impairment. If NSAID treatment is necessary between about 20 weeks and 30 weeks gestation, limit Diclona Gel use to the lowest effective dose and shortest duration possible. Serious Skin Reactions Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) has been reported in patients taking NSAIDs such as Diclona Gel. DRESS typically, although not exclusively, presents with fever, rash, lymphadenopathy, and/or facial swelling. 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. Avoid the use of Diclona Gel in patients with severe heart failure unless benefits are expected to outweigh the risk of worsening heart failure. If Diclona Gel is used in patients with severe heart failure, monitor patients for signs of worsening heart failure.

CONTRAINDICATIONS Diclona™ is contraindicated in patients with a known history of sensitivity to local anesthetics of the amide type, or to any other component of the product. Diclona Gel is contraindicated in patients with a known hypersensitivity to diclofenac sodium. Diclona Gel is contraindicated in patients in the setting of coronary artery bypass graft (CABG) surgery.

ADVERSE REACTIONS Application Site Reactions During or immediately after treatment with Diclona™, the skin at the site of application may develop blisters, bruising, burning sensation, depigmentation, dermatitis, discoloration, edema, erythema, exfoliation, irritation, papules, petechia, pruritus, vesicles, or may be the locus of abnormal sensation. These reactions are generally mild and transient, resolving spontaneously within a few minutes to hours. Other Adverse Events Due to the nature and limitation of spontaneous reports in post marketing surveillance, causality has not been established for additional reported adverse events including: Asthenia, confusion, disorientation, dizziness, headache, hyperesthesia, hypoesthesia, lightheadedness, metallic taste, nausea, nervousness, pain exacerbated, paresthesia, somnolence, taste alteration, vomiting, visual disturbances such as blurred vision, flushing, tinnitus, and tremor. Systemic (Dose-Related) Reactions Systemic adverse reactions following appropriate use of Diclona™ are unlikely, due to the small dose absorbed (see CLINICAL PHARMACOLOGY, Pharmacokinetics). Systemic adverse effects of lidocaine is similar in nature to those observed with other amide local anesthetic agents, including CNS excitation and/or depression (light headedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest). Excitatory CNS reactions may be brief or not occur at all, in which case the first manifestation may be drowsiness merging into unconsciousness. Cardiovascular manifestations may include bradycardia, hypotension and cardiovascular collapse leading to arrest.

CLINICAL PHARMACOLOGY Pharmacodynamics Lidocaine is an amide-type local anesthetic agent. The penetration of lidocaine into intact skin after application of Diclona Gel is sufficient to produce analgesic effect, but less than the amount necessary to produce a complete sensory block. The mechanism of action of diclofenac sodium in the treatment of actinic keratoses (AK) is unknown. The contribution to efficacy of individual components of the vehicle has not been established. Pharmacokinetics Absorption The amount of lidocaine systemically absorbed from Diclona Gel is directly related to both the duration of application and the surface area over which it is applied. When Diclona Gel is applied topically, diclofenac sodium is absorbed into the epidermis. The systematic bioavailability after topical application of diclofenac sodium is lower than after oral dosing. Distribution At concentrations produced by application of Diclona Gel, approximately 70% of the lidocaine dose is reported to be bound to plasma proteins, primarily alpha-1-acid glycoprotein. At higher plasma concentrations (1 to 4 mcg/mL of free base), the plasma protein binding of lidocaine is concentration dependent. Diclofenac sodium binds tightly to serum albumin. Metabolism It is not known if Diclona Gel is metabolized in the skin. Metabolism of diclofenac sodium following topical administration is thought to be similar to that after oral administration. The small amounts of diclofenac sodium and its metabolites appearing in the plasma following topical administration makes the quantification of specific metabolites imprecise. Excretion Lidocaine and its metabolites are excreted by the kidneys. Less than 10% of lidocaine is excreted unchanged. The half-life of lidocaine elimination from the plasma following IV administration is 81 to 149 minutes (mean 107 ± 22 SD, n = 15). The systemic clearance is 0.33 to 0.90 L/min (mean 0.64 ± 2 max max 0.18 SD, n = 15). Diclofenac sodium and its metabolites are excreted mainly in the urine after oral dosing.