Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

Cardiovascular safety of etoricoxib

The Lancet has recently published the results of the MEDAL study; an analysis of the cardiovascular safety of etoricoxib (Arcoxia®) in comparison to diclofenac.

The study recruited 34,701 patients (24,913 with osteoarthritis and 9,787 with rheumatoid arthritis) and treatment was provided for an average of 18 months. Thrombotic cardiovascular events occurred in 320 patients taking etoricoxib and 323 patients taking diclofenac. There was no statistical difference. Upper gastrointestinal clinical event rates were lower in the etoricoxib arm but there was no difference in the number of complicated events.

PharmaTimes have reported this trial with a headline of "Arcoxia as safe as diclofenac for heart effects".

As recently reported, the European Medicines Agency completed a review of the safety of non-steroidal anti-inflammatories (NSAID) and found that diclofenac carries a thrombotic risk. The study has already drawn criticism for this reason.

Low dose ibuprofen continues to be the first line choice when an NSAID is clinically appropriate. Second line options include naproxen and possibly diclofenac. In patients at risk of gastrointestinal events use lansoprazole or omeprazole to provide gastro-protection.

Action: Use of etoricoxib should be restricted to situations where alternative therapies, including paracetamol based analgesia and the NSAIDs specified above, have failed.

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