NSAID Selection and Management

Introduction to Etoricoxib

The American Heart Association states that etoricoxib does not appear to be among the first choices for pain relief with regard to safety, especially in individuals with or at risk for cardiovascular disease 2
For patients with cardiovascular disease or high risk factors, use a stepped-care approach starting with acetaminophen, aspirin, tramadol, or narcotic analgesics before considering NSAIDs 1
Etoricoxib is indicated for acute gouty arthritis at a dose of 120 mg once daily for 8 days 1
Use etoricoxib at the lowest effective dose for the shortest possible duration, typically 2-4 weeks for active treatment phase 1
Evaluate treatment response at 2-4 weeks after initiation, and consider switching to on-demand treatment or dose tapering with sustained sufficient response at 12 weeks 1

The maximum daily dose of diclofenac is 150 mg, and higher doses are associated with increased gastrointestinal and renal adverse effects 3
Diclofenac is not recommended for patients with active peptic ulcer disease, severe heart failure, liver failure, or history of GI bleeding 3
For acute pain management, intramuscular diclofenac 75 mg is the preferred route, providing rapid analgesia without the technical complexity and risks of IV administration 3
The intramuscular route of diclofenac has a minimum 12-hour interval between doses, with a maximum daily dose of 150 mg (two doses of 75 mg) 3

No particular NSAID is recommended as the preferred choice for ankylosing spondylitis or other inflammatory conditions, as head-to-head trials show no evidence of superiority between diclofenac and other NSAIDs 4, 5
Choice of NSAID should be based on patient's past history of NSAID use, risk factors for adverse effects, and comorbidities 4, 5
Monitor blood pressure, BUN, creatinine, liver function studies, CBC, and fecal occult blood at baseline and every 3 months in patients on chronic NSAID therapy 3

Assess cardiovascular risk, and if high risk or established cardiovascular disease, avoid etoricoxib and consider acetaminophen, tramadol, or narcotic analgesics first 1, 2
Assess gastrointestinal risk, and if active peptic ulcer disease or history of GI bleeding, avoid all NSAIDs 3
Check for contraindications, including severe heart failure, liver failure, renal impairment (CrCl <10 mL/min), and concomitant anticoagulants without close monitoring 3