For a patient with acute gout versus rheumatoid arthritis, should I prescribe etoricoxib 120 mg once daily or 90 mg once daily?

Etoricoxib Dosing for Acute Gout vs. Rheumatoid Arthritis

For acute gout, prescribe etoricoxib 120 mg once daily; for rheumatoid arthritis, prescribe 90 mg once daily. These are the established, evidence-based doses for each condition and should not be interchanged. 1, 2

Dosing Algorithm by Indication

Acute Gout Flare

• Etoricoxib 120 mg once daily is the recommended dose for acute gouty arthritis, representing the only COX-2 inhibitor specifically approved for this indication 1, 2
• The 120 mg dose provides effective analgesia comparable to traditional NSAIDs (naproxen, diclofenac, ibuprofen) for acute gout attacks 3, 4
• Continue at full 120 mg dose throughout the entire attack until complete symptom resolution; do not reduce the dose early 3

Rheumatoid Arthritis

• Etoricoxib 90 mg once daily is the recommended dose for chronic rheumatoid arthritis management 1, 5
• This dose demonstrated sustained efficacy over 121 weeks in head-to-head trials versus naproxen 500 mg twice daily, with comparable effectiveness 5
• The 90 mg dose is specifically calibrated for the chronic inflammatory burden of rheumatoid arthritis, which differs from the acute inflammatory cascade in gout 1

Critical Safety Considerations

Cardiovascular Contraindications

• Absolute contraindications: ischemic heart disease, stroke, uncontrolled hypertension 2
• Etoricoxib carries cardiovascular thrombotic risk similar to diclofenac, though possibly slightly higher than other traditional NSAIDs 4
• A combined analysis of 34,701 patients showed comparable thrombotic cardiovascular event rates between etoricoxib and diclofenac 4

Hypertension Monitoring

• Etoricoxib provokes arterial hypertension, edema, and heart failure more frequently than traditional NSAIDs 4
• Rates of discontinuation due to hypertension-related adverse effects are higher with etoricoxib than diclofenac 2
• Blood pressure monitoring is mandatory during treatment 2

Gastrointestinal Profile

• Etoricoxib reduces uncomplicated upper gastrointestinal adverse events by approximately 50% compared to diclofenac 3, 2
• However, it does not reduce the risk of perforation, ulcer, or severe gastrointestinal hemorrhage in long-term comparative trials (5,441 patients) 4
• The gastrointestinal advantage is limited to mild-to-moderate symptoms, not serious complications 4

Renal Considerations

• Use with extreme caution in patients with renal impairment, as with all NSAIDs 3
• Administer at the lowest effective dose for the shortest duration possible 3

Common Pitfalls to Avoid

• Do not use 90 mg for acute gout—the 120 mg dose is specifically indicated for the acute inflammatory burden of gout attacks 1
• Do not use 120 mg chronically for rheumatoid arthritis—the 90 mg dose is appropriate for long-term management 1, 5
• Do not prescribe etoricoxib to patients with uncontrolled hypertension—this is an absolute contraindication per European regulatory authorities 2
• Do not assume superior gastrointestinal safety eliminates serious GI risk—perforation and hemorrhage rates remain comparable to traditional NSAIDs 4
• Do not overlook drug interactions—etoricoxib is metabolized by CYP3A4 and increases ethinylestradiol bioavailability 4

Alternative Considerations

• For acute gout in patients with cardiovascular risk factors, consider colchicine (1.2 mg loading dose followed by 0.6 mg one hour later) or oral corticosteroids (prednisone 30–35 mg daily for 5 days) as safer alternatives 6
• For rheumatoid arthritis, traditional NSAIDs such as ibuprofen or naproxen have more extensive safety data and should be considered first-line when NSAID therapy is required 4
• Paracetamol remains the first-choice analgesic for joint pain when appropriate 4