What are the contraindications for Etoricoxib (Arcoxia)?

Contraindications for Etoricoxib

Etoricoxib is absolutely contraindicated in patients with ischemic heart disease, stroke, peripheral arterial disease, uncontrolled hypertension, active peptic ulcer disease or gastrointestinal bleeding, inflammatory bowel disease (with active flares), severe hepatic impairment, severe renal impairment (eGFR <30 mL/min), and for perioperative pain in the setting of coronary artery bypass graft (CABG) surgery. 1, 2

Absolute Cardiovascular Contraindications

• Established ischemic heart disease or cerebrovascular disease - Etoricoxib increases the risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal 1
• Uncontrolled hypertension - The European Medicines Agency has specifically contraindicated etoricoxib use in patients with uncontrolled hypertension, as the drug commonly causes hypertension and edema 3, 2
• Perioperative pain in CABG surgery - This is an FDA black box contraindication applicable to all NSAIDs including etoricoxib 1
• Congestive heart failure - Etoricoxib can provoke or exacerbate heart failure 4, 5

Absolute Gastrointestinal Contraindications

• Active peptic ulcer disease - NSAIDs including etoricoxib cause increased risk of serious gastrointestinal adverse events including inflammation, bleeding, ulceration, and perforation of the stomach or intestines 1
• Current active gastrointestinal bleeding - This represents an absolute contraindication to all NSAIDs 1
• History of gastrointestinal perforation, ulceration, or bleeding related to previous NSAID therapy 1

Absolute Renal Contraindications

• Severe renal impairment (eGFR <30 mL/min) - Etoricoxib should not be used in patients with chronic kidney disease 1, 3
• Progressive renal disease - The renal adverse effects of etoricoxib are similar to those of other NSAIDs 5

Absolute Hepatic Contraindications

• Severe hepatic impairment or active liver failure - Etoricoxib AUC increases by approximately 40% in patients with moderate hepatic impairment, making severe impairment an absolute contraindication 1, 5

Hypersensitivity Contraindications

• Known hypersensitivity to etoricoxib or any component of the formulation 1
• History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs - This indicates aspirin-exacerbated respiratory disease, though etoricoxib may be tolerated in 97% of patients with previous NSAID reactions 6

Relative Contraindications Requiring Extreme Caution

• Cardiovascular disease or risk factors for cardiovascular disease - Patients with or at risk for cardiovascular disease may be at greater risk, and a stepped-care approach starting with acetaminophen, aspirin, tramadol, or narcotic analgesics should be considered first 1, 7
• Hypertension (even if controlled) - Regular blood pressure monitoring is essential, as etoricoxib commonly causes hypertension 3, 8
• History of peptic ulcer disease (even if healed) - Co-prescription with a proton pump inhibitor is mandatory 1, 8
• Concomitant use of corticosteroids or SSRIs - These increase gastrointestinal bleeding risk 1
• Helicobacter pylori infection - This increases gastrointestinal risk 1
• Inflammatory bowel disease in remission - While short-term use (2-4 weeks) may be acceptable in quiescent IBD, traditional NSAIDs are relatively contraindicated due to risk of disease flare 7, 9
• Moderate hepatic impairment - Dose adjustment and careful monitoring required 5
• Elderly patients - Greater risk for serious gastrointestinal and renal events 1

Important Clinical Caveats

The American Heart Association specifically cautions against assuming etoricoxib is as safe as traditional NSAIDs in patients with cardiovascular disease 3, 7. The COX-2 selectivity of etoricoxib creates an imbalance by reducing endothelial prostacyclin production while leaving platelet thromboxane A2 intact, increasing thrombotic risk proportional to baseline patient cardiovascular risk 7.

When etoricoxib must be used despite relative contraindications, it should be prescribed at the lowest effective dose (60 mg for osteoarthritis, not 90 mg) for the shortest possible duration (2-4 weeks maximum for acute conditions), with mandatory gastroprotection via proton pump inhibitor co-prescription and regular monitoring of blood pressure, renal function, and cardiovascular status 3, 7, 8.