Selective COX-2 inhibitor (coxib)
Brand names: Arcoxia, Algix, Tauxib, Exxiv
Updated · Methodology
Second line
Symptomatic treatment of knee and hip osteoarthritis when pain persists despite paracetamol and topical NSAIDs. 2019 and 2023 set topical NSAIDs and paracetamol as first-line pharmacotherapy for osteoarthritis; oral NSAIDs including coxibs are second-line with shortest possible duration. Dose 30–60 mg daily.
Sources
ICD-10: M17 · ICD-11: FA01
Second line
Used for symptomatic relief in rheumatoid arthritis as an alternative to non-selective NSAIDs in patients at high gastrointestinal risk (ulcer history, age over 65, combination with anticoagulants or steroids). Does not modify disease course – 2022 builds treatment around DMARDs (methotrexate, sulfasalazine, leflunomide) plus biologics when needed. RA dose: 60–90 mg once daily.
Sources
ICD-10: M06.9 · ICD-11: FA20
Second line
Used in acute pain (dental, postoperative, musculoskeletal) in courses up to 8 days. Dose 90–120 mg once daily. Efficacy is comparable to ibuprofen 600 mg four times daily with better GI tolerability.
ICD-10: R52 · ICD-11: MG31
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Etoricoxib is a selective cyclooxygenase-2 inhibitor (coxib). It is prescribed for osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and gout (AEMPS Ficha Técnica). In anti-aging regimens, etoricoxib is positioned as a selective coxib without ulcer risks for long-term suppression of low-grade aging-related inflammation. Long-term use in people without a confirmed inflammatory disease is not justified: 2020 and 2023 do not include NSAIDs in age-related prevention. COX-2 selectivity reduces GI bleeding risk but raises cardiovascular risk: the MEDAL 2007 meta-analysis showed that etoricoxib is associated with greater blood-pressure elevation and heart-failure risk than nonselective NSAIDs. If etoricoxib was prescribed for chronic anti-inflammatory use, consider seeking a second opinion.
A highly selective reversible COX-2 inhibitor with COX-2/COX-1 ratio of about 106:1 in vitro. Reduces pro-inflammatory prostaglandin synthesis at the inflammation site without blocking gastric COX-1 – less gastroduodenal erosion and ulcer risk than non-selective NSAIDs. Half-life 22 hours allows once-daily dosing. Not -approved in the US due to cardiovascular risk; widely prescribed in Europe and Latin America.
Contraindicated in T3 – risk of premature ductus arteriosus closure, oligohydramnios, and fetal renal dysfunction. T1 and T2 use is not recommended without clear indication.
Limited data. Ibuprofen with more data is preferred during lactation.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
3 pairs found. Sorted from critical to minor.
Mechanism
In a gout flare both are used, but along routes whose adverse effects overlap: colchicine damages intestinal mucosa while etoricoxib inhibits COX-2 with renal and blood pressure impact. The colchicine label warns that macrolides, CYP3A4 inhibitors, ciclosporin, protease inhibitors, calcium antagonists and statins raise its levels and can cause toxicity; etoricoxib is not on that list, so the risk here is additive rather than metabolic.
Symptoms
Diarrhoea, nausea and abdominal pain come first and are the classic warning of excess colchicine. Etoricoxib adds oedema, rising blood pressure and reduced urine output. Muscle weakness with dark urine points to colchicine myopathy, especially with statins or low renal filtration.
Management
In a flare use the short low-dose colchicine regimen and keep etoricoxib as brief as possible, watching blood pressure and oedema. Diarrhoea marks the colchicine ceiling: once it appears, reduce or stop. With low renal filtration or statins, review the colchicine dose before starting.
Sources
Mechanism
Rivaroxaban blocks coagulation factor Xa; etoricoxib selectively inhibits cyclooxygenase-2 (COX-2) and by itself causes upper gastrointestinal ulcers, perforations and bleeding, some of them fatal (etoricoxib SmPC, AEMPS, section 4.4). Etoricoxib has no antiplatelet effect (etoricoxib SmPC, 4.4), but it damages the mucosa, and on an anticoagulant such damage bleeds more. The rivaroxaban SmPC lists NSAIDs among drugs that affect haemostasis and asks for caution (, 4.4 and 4.5). There is no kinetic conflict: etoricoxib does not affect CYP3A4 (etoricoxib SmPC, 4.5), the enzyme that clears rivaroxaban. Etoricoxib adds a second factor through the kidney: NSAIDs can impair renal function (etoricoxib SmPC, 4.4), and in renal impairment rivaroxaban concentrations rise (rivaroxaban SmPC, 4.4).
Symptoms
Above all gastrointestinal bleeding: black or bloody stools, vomiting blood, abdominal pain, weakness, a fall in haemoglobin. The rivaroxaban SmPC lists mucosal bleeding (nosebleeds, gums, gastrointestinal, genitourinary including heavier menstrual bleeding) and anaemia, and requires a search for the bleeding site after any unexplained fall in haemoglobin or blood pressure (, 4.4). From etoricoxib separately: fluid retention, oedema, a rise in blood pressure, worsening renal function (etoricoxib SmPC, AEMPS, 4.4). Uncontrolled hypertension and renal impairment in a patient on rivaroxaban are also bleeding risk factors (rivaroxaban SmPC, 4.4).
Management
The combination is acceptable with caution; no label forbids it. The rivaroxaban SmPC asks for caution with concomitant NSAIDs because of the bleeding risk (, 4.4 and 4.5), and the etoricoxib SmPC asks for caution with warfarin and other oral anticoagulants (AEMPS, 4.4). The EHRA 2021 practical guide advises weighing such a combination against the expected benefit in each clinical situation. First check the etoricoxib contraindications: active peptic ulcer or gastrointestinal bleeding, uncontrolled hypertension above 140/90 mmHg, congestive heart failure, ischaemic heart disease, peripheral arterial or cerebrovascular disease, creatinine clearance below 30 mL/min (etoricoxib SmPC, 4.3). Rivaroxaban is also contraindicated with an active or recent ulcer (rivaroxaban SmPC, 4.3). Give etoricoxib at the lowest effective dose for the shortest possible time (etoricoxib SmPC, 4.4), and in patients at risk of ulcer disease consider prophylactic treatment (rivaroxaban SmPC, 4.4). Monitoring: watch for signs of bleeding and anaemia; haemoglobin and haematocrit help to detect occult bleeding (rivaroxaban SmPC, 4.4); promptly evaluate any sign of blood loss in a patient on an NSAID (rivaroxaban label, 7.4). The etoricoxib requirement to monitor the INR closely is written for warfarin. The INR does not measure the effect of rivaroxaban, routine monitoring is not needed, and a calibrated anti-Xa assay is reserved for exceptional situations (rivaroxaban SmPC, EMA, 4.4; FDA, 5.2). Check blood pressure during the first two weeks of etoricoxib and periodically afterwards (etoricoxib SmPC, 4.4). If renal function worsens, use rivaroxaban with caution at creatinine clearance 15–29 mL/min and do not use it below 15 mL/min (rivaroxaban SmPC, 4.4). Stop rivaroxaban in case of severe bleeding (EMA, 4.4).
Sources
Mechanism
Each occupies a different place in gout treatment: allopurinol lowers urate long term while etoricoxib quells flare inflammation. Neither label names the other substance in its interactions section, and allopurinol reserves its warnings for azathioprine, mercaptopurine and coumarin anticoagulants.
Symptoms
The pair produces no distinct picture. Watch each one separately: skin rash when starting allopurinol, which requires stopping it, and from etoricoxib high blood pressure, oedema and gastric discomfort.
Management
Allopurinol started during a flare can prolong it, which is why it is combined with anti-inflammatory or colchicine cover for the first months. If allopurinol was already being taken before the attack, it is not interrupted: stopping it shifts urate and lengthens the flare. Etoricoxib is withdrawn once inflammation settles.
Sources
Verbatim lines from the interaction sections, in the language of the label
«Etoricoxib puede utilizarse concomitantemente con ácido acetilsalicílico a las dosis utilizadas para la profilaxis cardiovascular (dosis baja de ácido acetilsalicílico). Sin embargo, la…»AEMPS, section 4.5 · Open on CIMA
«Anticoagulantes orales: en sujetos estabilizados con un tratamiento crónico con warfarina, la administración de 120 mg diarios de etoricoxib se asoció a un aumento aproximado del 13 % del índice de…»AEMPS, section 4.5 · Open on CIMA
«Diuréticos, inhibidores de la ECA y antagonistas de la angiotensina II: los AINEs pueden reducir el efecto de los diuréticos y de otros fármacos antihipertensivos. En algunos pacientes con función…»AEMPS, section 4.5 · Open on CIMA
«Ciclosporina y tacrolimus: aunque esta interacción no se ha estudiado con etoricoxib, la administración conjunta de ciclosporina o tacrolimus con cualquier AINE puede aumentar el efecto nefrotóxico…»AEMPS, section 4.5 · Open on CIMA
«Diuréticos, inhibidores de la ECA y antagonistas de la angiotensina II: los AINEs pueden reducir el efecto de los diuréticos y de otros fármacos antihipertensivos. En algunos pacientes con función…»AEMPS, section 4.5 · Open on CIMA
«Etoricoxib es un inhibidor de la actividad de la sulfotransferasa humana, particularmente la SULT1E1, y se ha demostrado que aumenta las concentraciones séricas de etinilestradiol. Mientras que el…»AEMPS, section 4.5 · Open on CIMA
«Diuréticos, inhibidores de la ECA y antagonistas de la angiotensina II: los AINEs pueden reducir el efecto de los diuréticos y de otros fármacos antihipertensivos. En algunos pacientes con función…»AEMPS, section 4.5 · Open on CIMA
«El efecto de etoricoxib sobre la farmacocinética de otros fármacos: Litio: los AINEs disminuyen la excreción renal de litio y por tanto aumentan los niveles plasmáticos de litio. Puede ser necesario…»AEMPS, section 4.5 · Open on CIMA
«El efecto de etoricoxib sobre la farmacocinética de otros fármacos: Metotrexato: dos estudios investigaron los efectos de etoricoxib 60, 90 o 120 mg, administrado una vez al día durante siete días en…»AEMPS, section 4.5 · Open on CIMA
«Etoricoxib es un inhibidor de la actividad de la sulfotransferasa humana, particularmente la SULT1E1, y se ha demostrado que aumenta las concentraciones séricas de etinilestradiol. Mientras que el…»AEMPS, section 4.5 · Open on CIMA
«Rifampicina: la administración conjunta de etoricoxib con rifampicina, un inductor potente de las enzimas del CYP, produjo una disminución del 65% en las concentraciones plasmáticas de etoricoxib…»AEMPS, section 4.5 · Open on CIMA
«Ciclosporina y tacrolimus: aunque esta interacción no se ha estudiado con etoricoxib, la administración conjunta de ciclosporina o tacrolimus con cualquier AINE puede aumentar el efecto nefrotóxico…»AEMPS, section 4.5 · Open on CIMA
«Anticoagulantes orales: en sujetos estabilizados con un tratamiento crónico con warfarina, la administración de 120 mg diarios de etoricoxib se asoció a un aumento aproximado del 13 % del índice de…»AEMPS, section 4.5 · Open on CIMA
«El efecto de etoricoxib sobre la farmacocinética de otros fármacos: Digoxina: etoricoxib 120 mg administrado una vez al día durante 10 días a voluntarios sanos no alteró el AUC 0-24h plasmático del…»AEMPS, section 4.5 · Open on CIMA
«Antiácidos: los antiácidos no afectan a la farmacocinética de etoricoxib de forma clínicamente relevante.»AEMPS, section 4.5 · Open on CIMA
«El efecto de etoricoxib sobre la farmacocinética de otros fármacos: Anticonceptivos orales: etoricoxib 60 mg administrado concomitantemente con un anticonceptivo oral que contenía 35 microgramos de…»AEMPS, section 4.5 · Open on CIMA
«Según los estudios in vitro , no cabe esperar que etoricoxib inhiba los citocromos P450 (CYP) 1A2, 2C9, 2C19, 2D6, 2E1 o 3A4. En un estudio en sujetos sanos, la administración diaria de etoricoxib…»AEMPS, section 4.5 · Open on CIMA
«El efecto de etoricoxib sobre la farmacocinética de otros fármacos: Terapia hormonal sustitutiva (THS): la administración de etoricoxib 120 mg con terapia hormonal sustitutiva que contenía estrógenos…»AEMPS, section 4.5 · Open on CIMA
«Voriconazol y Miconazol : la administración conjunta de voriconazol oral o gel oral de miconazol para uso tópico, inhibidores potentes del CYP3A4, con etoricoxib causó un ligero aumento en la…»AEMPS, section 4.5 · Open on CIMA
«Ketoconazol: ketoconazol, un inhibidor potente del CYP3A4, administrado a voluntarios sanos, a dosis de 400 mg una vez al día durante 11 días, no tuvo ningún efecto clínicamente importante en la…»AEMPS, section 4.5 · Open on CIMA
«Voriconazol y Miconazol : la administración conjunta de voriconazol oral o gel oral de miconazol para uso tópico, inhibidores potentes del CYP3A4, con etoricoxib causó un ligero aumento en la…»AEMPS, section 4.5 · Open on CIMA
«El efecto de etoricoxib sobre la farmacocinética de otros fármacos: Anticonceptivos orales: etoricoxib 60 mg administrado concomitantemente con un anticonceptivo oral que contenía 35 microgramos de…»AEMPS, section 4.5 · Open on CIMA
«El efecto de etoricoxib sobre la farmacocinética de otros fármacos: Prednisona/AEMPS, section 4.5 · Open on CIMA
«El efecto de etoricoxib sobre la farmacocinética de otros fármacos: Prednisona/AEMPS, section 4.5 · Open on CIMA
«Voriconazol y Miconazol : la administración conjunta de voriconazol oral o gel oral de miconazol para uso tópico, inhibidores potentes del CYP3A4, con etoricoxib causó un ligero aumento en la…»AEMPS, section 4.5 · Open on CIMA
«Sustancias que disminuyen el aclaramiento de los AOCS (inhibidores enzimáticos): Se ha demostrado que dosis de etoricoxib de 60 a 120 mg/AEMPS, section 4.5 · Open on CIMA
«La relevancia clínica de las interacciones potenciales con inhibidores enzimáticos sigue siendo desconocida. Los inhibidores potentes y moderados del CYP3A4, tales como los antifúngicos azólicos (p…»AEMPS, section 4.5 · Open on CIMA
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Etoricoxib is evaluated for the following indications with varying evidence strength: Rheumatoid arthritis (evidence tier A), Knee osteoarthritis (evidence tier A), Mild to moderate pain in adults (evidence tier B). See the full indication matrix with dosing and citations above on this page.
Common side effects of Etoricoxib (≥ 1 in 100): Elevated blood pressure, Edema, Dizziness, Headache, Dyspepsia, nausea, Elevated liver enzymes. See the Safety section for uncommon and serious reactions.
Contraindicated in T3 – risk of premature ductus arteriosus closure, oligohydramnios, and fetal renal dysfunction. T1 and T2 use is not recommended without clear indication.
Limited data. Ibuprofen with more data is preferred during lactation.
Etoricoxib is contraindicated in: Hypersensitivity to etoricoxib or other coxibs; Active peptic ulcer, GI bleeding; Inflammatory bowel disease; Severe hepatic impairment; Renal impairment with eGFR under 30. Full list in the Safety section.
Direct links to regulator labels. Open in a new tab.
Glucosamine, Glucosamine + Chondroitin, Ibuprofen, Ketoprofen, Lornoxicam, Nimesulide, Boswellia, Ketorolac