What are the guidelines for using Etoricoxib (generic name for Arcoxia, a COX-2 inhibitor NSAID)?

Guidelines for Using Etoricoxib (Arcoxia)

Etoricoxib should not be a first-line treatment for pain or inflammation due to its significant cardiovascular risks, and is contraindicated in patients with ischemic heart disease, stroke, or uncontrolled hypertension. 1

Indications and Dosing

Etoricoxib is a selective COX-2 inhibitor NSAID approved in various countries (not in the US) for:

• Osteoarthritis: 60 mg once daily 1
• Rheumatoid arthritis: 90 mg once daily 1
• Acute gouty arthritis: 120 mg once daily 1
• Ankylosing spondylitis: 90 mg once daily 1
• Acute pain and primary dysmenorrhea: 120 mg once daily 2

Risk Assessment Before Prescribing

Cardiovascular Risk

• High-risk patients: Etoricoxib is contraindicated in patients with:

  • Established ischemic heart disease
  • Cerebrovascular disease (stroke)
  • Uncontrolled hypertension 1
  • Recent CABG surgery 3

• Moderate-risk patients: Use with extreme caution in patients with:

  • Cardiovascular risk factors (hypertension, hyperlipidemia, diabetes, smoking)
  • Peripheral arterial disease 4

Gastrointestinal Risk

• While etoricoxib has improved GI safety compared to non-selective NSAIDs, patients with the following remain at increased risk:
  • History of peptic ulcer disease
  • Age >65 years
  • Concurrent use of anticoagulants, corticosteroids, or aspirin
  • Smoking or alcohol use 4

Treatment Algorithm

1. First-line treatments (before considering etoricoxib):

   • Non-pharmacological approaches (exercise, weight loss if applicable)
   • Paracetamol (acetaminophen) 4
   • Topical NSAIDs (for OA of knees/hands) 4

2. Second-line options (if first-line inadequate):

   • Non-selective NSAIDs with lower cardiovascular risk (e.g., naproxen)
   • Consider etoricoxib only in patients with:
     • Low cardiovascular risk
     • High gastrointestinal risk
     • Inadequate response to other treatments 4

3. When using etoricoxib:

   • Use lowest effective dose for shortest duration
   • Add PPI for patients with GI risk factors
   • Monitor blood pressure regularly
   • Discontinue if hypertension develops or worsens 4

Special Considerations

Concomitant Aspirin Use

• Concomitant low-dose aspirin reduces the GI benefit of COX-2 selectivity
• If aspirin is needed for cardiovascular protection, consider alternative analgesics 4

Renal Function

• Monitor renal function in patients with:
  • Pre-existing renal impairment
  • Heart failure
  • Liver dysfunction
  • Dehydration
  • Concurrent use of diuretics or ACE inhibitors 3

Elderly Patients

• Start with lowest effective dose
• More frequent monitoring for adverse effects
• Higher risk of both cardiovascular and GI complications 4

Monitoring During Treatment

• Blood pressure: Before starting treatment and periodically thereafter
• Renal function: In at-risk patients
• Signs of GI bleeding: Educate patients about warning signs
• Cardiovascular symptoms: Instruct patients to report chest pain, shortness of breath, or stroke symptoms immediately 3

Important Warnings

• The MEDAL program showed etoricoxib had similar cardiovascular risk to diclofenac, but both are considered to have higher cardiovascular risk than other NSAIDs 4
• Etoricoxib has a higher COX-2 selectivity ratio than other COX-2 inhibitors, which may theoretically increase thrombotic risk 5
• European Medicines Agency has specifically contraindicated etoricoxib in patients with uncontrolled hypertension 1
• Discontinue immediately if signs of liver toxicity, severe skin reactions, or anaphylactoid reactions occur 3

By following these guidelines and carefully selecting appropriate patients, etoricoxib can be used effectively while minimizing risks of serious adverse events.