What is the recommended dosing for etoricoxib (Arcoxia) in the treatment of arthritis?

Etoricoxib Dosing for Arthritis

For rheumatoid arthritis, etoricoxib 90 mg once daily is the recommended dose, while for osteoarthritis and ankylosing spondylitis, 60 mg once daily is the standard starting dose. 1, 2

Dosing by Arthritis Type

Rheumatoid Arthritis

• Standard dose: 90 mg once daily 1, 2
• Etoricoxib 90 mg has demonstrated superior efficacy to placebo and equivalent efficacy to naproxen 500 mg twice daily in multiple controlled trials 2, 3
• While 60 mg once daily also shows efficacy in RA, the 90 mg dose provides statistically significant (though modest) additional improvement in pain scores compared to 60 mg 2
• Dose escalation from 60 mg to 90 mg in patients with inadequate pain relief on 60 mg does not provide significant additional benefit, suggesting that patients who will respond to 90 mg typically do so from the start 2

Osteoarthritis

• Standard dose: 60 mg once daily 1, 4
• This dose has demonstrated sustained efficacy over 138 weeks of treatment, with similar effectiveness to naproxen 500 mg twice daily 4
• Long-term treatment maintains efficacy without evidence of tolerance development 4

Ankylosing Spondylitis

• Standard dose: 60 mg once daily 1, 5
• Both 60 mg and 90 mg doses are non-inferior to naproxen 1000 mg daily for spinal pain control 5
• 60 mg once daily is the lowest effective dose for most patients with AS 5
• Dose escalation from 60 mg to 90 mg in inadequate responders (defined as <50% improvement in spinal pain) does not provide clinically meaningful additional benefit 5

Acute Gouty Arthritis

• Acute gout dose: 120 mg once daily for 8 days 6

Treatment Duration and Monitoring

Short-term vs. Continuous Use

• Use at the lowest effective dose for the shortest possible duration, typically 2-4 weeks for the active treatment phase 6
• Evaluate treatment response at 2-4 weeks after initiation 6
• With sustained sufficient response at 12 weeks, consider switching to on-demand treatment or dose tapering 6
• For chronic inflammatory conditions requiring longer treatment, re-evaluate at 12 weeks to determine if continuous therapy remains necessary 6

Safety Monitoring Requirements

• Monitor blood pressure during treatment, as hypertension and edema are common side effects 6
• For patients requiring long-term treatment, monitor renal function and liver function regularly 6
• Assess cardiovascular risk factors before initiating therapy, particularly uncontrolled hypertension 7

Cardiovascular Risk Stratification

High-Risk Patients (Avoid or Use Extreme Caution)

• Etoricoxib is absolutely contraindicated in patients with established ischemic heart disease or cerebrovascular disease 7
• Contraindicated in perioperative pain management for CABG surgery 7
• For patients with or at high risk for cardiovascular disease, consider alternative pain management first: acetaminophen, tramadol, or topical NSAIDs 7, 6
• The American Heart Association cautions against assuming etoricoxib is as safe as traditional NSAIDs in cardiovascular disease patients 7, 6

Mechanism of Cardiovascular Risk

• Etoricoxib has higher COX-1/COX-2 selectivity than other COX-2 inhibitors (rofecoxib, valdecoxib, celecoxib) 1
• COX-2 selectivity reduces endothelial prostacyclin production while leaving platelet thromboxane A2 intact, creating a prothrombotic state 6
• Risk is proportional to both COX-2 selectivity and the patient's underlying cardiovascular risk 6

Gastrointestinal Protection

Risk Assessment

• Etoricoxib is contraindicated in active peptic ulcer disease or current gastrointestinal bleeding 7
• History of peptic ulcer disease (even if healed) requires co-prescription of a proton pump inhibitor 7
• Concomitant corticosteroids or SSRIs increase GI bleeding risk and should be avoided if possible 7
• Helicobacter pylori infection should be treated before initiating etoricoxib 7

Gastroprotection Strategy

• Co-prescribe a proton pump inhibitor for patients with GI risk factors 7
• Despite superior GI safety compared to non-selective NSAIDs, etoricoxib still carries GI risk requiring prophylaxis in vulnerable patients 7

Renal and Hepatic Considerations

Renal Impairment

• Do not use etoricoxib with eGFR <30 mL/min 7
• Monitor renal function, especially in elderly patients 7

Hepatic Impairment

• Severe hepatic impairment or active liver failure is an absolute contraindication 7
• AUC increases by approximately 40% in moderate hepatic impairment 7

Common Pitfalls to Avoid

1. Do not use 90 mg dosing for osteoarthritis or ankylosing spondylitis - these conditions respond adequately to 60 mg with lower risk 1, 5

2. Do not escalate doses in non-responders without adequate trial duration - patients who will respond typically do so within 2-4 weeks at the initial dose 2, 5

3. Do not assume etoricoxib is safer than traditional NSAIDs in cardiovascular disease - its high COX-2 selectivity may increase thrombotic risk 7, 6

4. Do not continue long-term without periodic reassessment - evaluate at 12 weeks whether continuous therapy remains necessary or if on-demand treatment suffices 6

5. Do not overlook blood pressure monitoring - hypertension is a common side effect requiring surveillance 6