Cox-2 inhibitors

Cardiovascular risk: COX-2s cause a small increased risk of thrombotic events, (e.g. myocardial infarction and stroke), compared with placebo and the risk may increase with dose and duration of exposure. Patients with established ischaemic heart disease or cerebovascular disease should not take COX-2 inhibitors.

Aspirin: the addition of a COX-2 inhibitor to low-dose aspirin increases ulcer incidence to a rate similar to NSAIDs alone. It is advised to avoid co-prescribing with low-dose aspirin as there is no benefit in terms of gastrointestinal safety.

Indications: COX-2s should be used only when specifically indicated, (i.e. for patients who are at a particularly high risk of developing gastroduodenal ulcer, perforation or bleeding) and after an assessment of cardiovascular risk. The lowest effective dose of COX-2 inhibitor should be used for the shortest necessary period.

Celecoxib is licensed for pain and inflammation in osteoarthritis or rheumatoid arthritis only and not for acute pain. Monitor blood pressure before and during treatment.

Etoricoxib is licensed for the relief of pain associated with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis and gout. It is available as an alternative to celecoxib. For gout, the recommended dose is 120mg daily; this may be used in the acute phase for up to 8 days. Monitor blood pressure before and during treatment.