Etoricoxib

# Etoricoxib ## Overview - **Classification**: Cyclooxygenase-2 (COX-2) selective non-steroidal anti-inflammatory drug (NSAID) - **Mechanism**: Potent and highly selective inhibitor of COX-2, reducing prostaglandin synthesis. This provides anti-inflammatory, analgesic, and antipyretic effects while theoretically minimizing GI side effects associated with non-selective NSAIDs. ## Primary Indications 1. **Osteoarthritis (OA)** - Symptomatic relief of pain and inflammation. 2. **Rheumatoid Arthritis (RA)** - Symptomatic relief of pain and inflammation. 3. **Ankylosing Spondylitis (AS)** - Symptomatic relief of pain and inflammation. 4. **Acute Gouty Arthritis** - Short-term treatment of acute attacks. 5. **Acute Pain** - Relief of moderate-to-severe pain (e.g., post-operative dental surgery). 6. **Primary Dysmenorrhea** - Relief of menstrual pain. ## Adult Dosing ### Standard Dosing **Osteoarthritis** - **Dose**: **30 mg** or **60 mg** - **Frequency**: Once daily (OD) - **Route**: Oral - **Duration**: Chronic, as needed for symptoms, at lowest effective dose. **Rheumatoid Arthritis & Ankylosing Spondylitis** - **Dose**: **60 mg** or **90 mg** - **Frequency**: Once daily (OD) - **Route**: Oral - **Duration**: Chronic, as needed for symptoms, at lowest effective dose. **Acute Gouty Arthritis** - **Dose**: **120 mg** - **Frequency**: Once daily (OD) - **Route**: Oral - **Duration**: Max **8 days**. **Acute Pain (e.g., Post-operative Dental Surgery Pain)** - **Dose**: **90 mg** or **120 mg** - **Frequency**: Once daily (OD) - **Route**: Oral - **Duration**: Max **5-8 days** (short-term treatment only). **Primary Dysmenorrhea** - **Dose**: **90 mg** - **Frequency**: Once daily (OD) - **Route**: Oral - **Duration**: Max **5 days**. ### Dose Adjustments - **Renal Impairment**: Not recommended for severe renal impairment (CrCl < 30 mL/min). Use caution in moderate impairment. - **Hepatic Impairment**: - Mild (Child-Pugh score 5-6): Max **60 mg OD**. - Moderate (Child-Pugh score 7-9): Max **30 mg OD**. - Severe (Child-Pugh score > 9): **Contraindicated**. - **Elderly Patients**: No specific dose adjustment needed. Use caution due to increased risk of cardiovascular and gastrointestinal side effects. ## Pediatric Dosing *Etoricoxib is generally **not approved** for use in children under 16 years of age.* ### Neonates (0-28 days) - **Etoricoxib is contraindicated in neonates.** ### Infants (1-12 months) - **Etoricoxib is contraindicated in infants.** ### Children (1-12 years) - **Etoricoxib is contraindicated in children.** ### Adolescents (13-18 years) - Etoricoxib is **not approved for patients under 16 years**. - For adolescents **≥ 16 years**, adult dosing may apply, but use with caution and only if clearly indicated by a specialist. ## Safety Information ### Contraindications - **Absolute**: Hypersensitivity to etoricoxib, aspirin, or other NSAIDs. - **Absolute**: Active peptic ulceration or gastrointestinal (GI) bleeding. - **Absolute**: Severe hepatic dysfunction (Child-Pugh > 9). - **Absolute**: Severe renal impairment (CrCl < 30 mL/min). - **Absolute**: Congestive heart failure (NYHA Class II-IV). - **Absolute**: Established ischemic heart disease, peripheral arterial disease, and/or cerebrovascular disease. - **Absolute**: Uncontrolled hypertension (BP consistently >140/90 mmHg and not adequately controlled). - **Absolute**: Pregnancy and breastfeeding. ### Common Adverse Effects - **Very Common (>10%)**: Hypertension. - **Common (1-10%)**: Dizziness, headache, palpitations, arrhythmias, GI discomfort, abdominal pain, diarrhea, nausea, edema (fluid retention). - **Serious but Rare**: GI perforation, ulceration, bleeding; thrombotic events (myocardial infarction, stroke); severe hypersensitivity reactions (anaphylaxis, Stevens-Johnson syndrome); acute renal failure; hepatic failure. ### Key Drug Interactions - **Warfarin/Other Anticoagulants**: Increased INR and bleeding risk. Monitor INR closely, adjust anticoagulant dose. - **Methotrexate**: Increased methotrexate plasma concentrations and toxicity. Monitor for adverse effects (e.g., myelosuppression). - **Lithium**: Increased lithium plasma concentrations and toxicity. Monitor lithium levels. - **ACE Inhibitors/ARBs/Diuretics**: Reduced antihypertensive effect; increased risk of renal impairment. Monitor blood pressure and renal function. - **Oral Contraceptives**: Increased ethinyl estradiol and norethindrone concentrations. Consider alternative contraception. - **Cyclosporine/Tacrolimus**: Increased risk of nephrotoxicity. ## Monitoring & Follow-up - **Before Treatment**: - Assess cardiovascular risk factors (e.g., hypertension, dyslipidemia, diabetes, smoking). - Check baseline renal function (SCr, eGFR) and hepatic function (LFTs). - Evaluate history of GI bleeding, peptic ulcers, or inflammatory bowel disease. - **During Treatment**: - Monitor blood pressure regularly, especially in patients with hypertension. - Monitor for signs/symptoms of GI bleeding (e.g., black, tarry stools, severe abdominal pain). - Monitor for signs of fluid retention, edema, and weight gain. - Periodically monitor renal and hepatic function, especially with long-term use. - **Clinical Signs**: Advise patients to report any chest pain, shortness of breath, sudden weakness/numbness, severe abdominal pain, or unusual bruising/bleeding. ## Clinical Pearls - 💡 **Cardiovascular Risk**: Use the lowest effective dose for the shortest duration possible, especially in patients with existing CV risk factors or disease. - 💡 **GI Protection**: Consider co-prescription of a proton pump inhibitor (PPI) for patients at high risk of GI adverse events (e.g., history of ulcer, concomitant aspirin). - 💡 **Blood Pressure Management**: Etoricoxib can elevate blood pressure. Ensure hypertension is well-controlled before starting therapy and monitor closely during treatment. - 💡 **Initiation Timing**: For acute pain, etoricoxib can be taken with or without food. Taking with food may slightly delay absorption but does not affect total absorption. > **⚠️ Important**: This information is for educational purposes only. Always consult current prescribing information, local guidelines, and clinical judgment before prescribing.