Etoricoxib - analgesia guidelines for acute pain management in adults

NHS Borders clinical guidelines
NHS Borders

Patients at high risk of NSAID-induced GI adverse events or surgical/traumatic bleeding

 

Etoricoxib is a highly selective cyclo-oxygenase-2 (COX-2) inhibitor. COX-2 is the inducible isoform of cyclo-oxygenase whose expression is markedly increased in response to inflammatory stressors. In contrast, COX-1 is the constitutive isoform whose activity predominates during normal physiological conditions. NSAID therapeutic & anti-inflammatory activity results primarily from their inhibition of COX-2 whereas toxicity, antiplatelet activity & adverse effects result mainly from COX-1 inhibition.

 

  • similar efficacy to conventional non-selective NSAIDs in the treatment of rheumatoid arthritis, osteoarthritis and acute post-surgical pain conditions
  • causes significantly less erosion and ulceration of the gastroduodenal mucosa and fewer clinical gastrointestinal adverse events than non-selective NSAIDS
  • has minimal antiplatelet activity and therefore does not confer antithrombotic cardiovascular protection
  • may be considered off-license for the short-term (7 days) management of acute pain of moderate severity in patients who would otherwise be at high risk of gastrointestinal adverse events if prescribed conventional NSAIDs
  • not for re-prescription by GP
  • licensed only for arthritis and gout
  • should not replace ibuprofen or diclofenac as the first-line NSAIDs post-operatively
  • no evidence to justify the simultaneous prescribing of gastroprotective agents with etoricoxib

Contraindications

Contraindications include:

  • history of hypersensitivity to aspirin or any other NSAID
  • active peptic ulcer disease (ie patients on treatment) or GI bleeding
  • established ischaemic heart disease, peripheral arterial disease or cerebrovascular disease
  • mild to severe heart failure
  • inadequately controlled hypertension (persistently more than 140/90 mmHg)
  • inflammatory bowel disease
  • pregnancy and breastfeeding
  • severe liver disease
  • renal impairment eGFR less than 30ml/min/1.73m2

Cautions

Caution should be observed in:

  • allergic disorders
  • cardiac impairment
  • coagulation defects
  • dehydration
  • left ventricular dysfunction
  • hypertension
  • oedema
  • the elderly
  • hepatic or mild renal impairment

Rare but potentially serious or fatal hypersensitivity and/or severe skin reactions are possible with COX-2 inhibitors – this risk is increased in patients with a history of drug allergy. The drug should be immediately discontinued if an adverse reaction of this type occurs.

Cardiovascular side effects are related to dose and duration of treatment therefore consider lower doses in those at high risk and maximum 7 days.

Dosing

Loading dose - 90mg in low risk patients only, then 60mg daily for 6 further days (consider 90mg if low risk or 60mg ineffective).

Editorial Information

Last reviewed: 28/02/2022

Next review date: 28/02/2025

Author(s): Smith S.

Version: 2

Author email(s): shona.smith@borders.scot.nhs.uk.

Approved By: Acute Pain Service

Reviewer name(s): Smith S.

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