Etoricoxib
Clinical data
AHFS/Drugs.comInternational Drug Names
Pregnancy
category
  • AU: C
  • Not recommended
Routes of
administration
By mouth
ATC code
Legal status
Legal status
  • AU: S4 (Prescription only)
  • BR: Class C1 (Other controlled substances)[1]
  • UK: POM (Prescription only)
Pharmacokinetic data
Bioavailability100%
Protein binding92%
MetabolismHepatic, CYP extensively involved (mainly CYP3A4)
Elimination half-life22 hours
ExcretionRenal (70%) and fecal (20%)
Identifiers
  • 5-Chloro-6'-methyl-3-[4-(methylsulfonyl)phenyl]-2,3'-bipyridine
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.207.709 Edit this at Wikidata
Chemical and physical data
FormulaC18H15ClN2O2S
Molar mass358.84 g·mol−1
3D model (JSmol)
  • O=S(=O)(c3ccc(c2cc(Cl)cnc2c1cnc(cc1)C)cc3)C
  • InChI=1S/C18H15ClN2O2S/c1-12-3-4-14(10-20-12)18-17(9-15(19)11-21-18)13-5-7-16(8-6-13)24(2,22)23/h3-11H,1-2H3 checkY
  • Key:MNJVRJDLRVPLFE-UHFFFAOYSA-N checkY
  (verify)

Etoricoxib, sold under the trade name Arcoxia, is a selective COX-2 inhibitor developed and commercialized by Merck. It is approved in 63 countries worldwide as of 2007, except the United States where the Food and Drug Administration sent a Non Approvable Letter to Merck and required them to provide additional data.[2]

It was patented in 1996 and approved for medical use in 2002.[3]

Medical uses

Etoricoxib is indicated for "the symptomatic relief of osteoarthritis (OA), rheumatoid arthritis (RA), ankylosing spondylitis, and the pain and signs of inflammation associated with acute gouty arthritis."[4]

Efficacy

A Cochrane review assessed the benefits of single-dose etoricoxib in the reduction of acute post-operative pain in adults.[5] Single-dose oral etoricoxib provides four times more pain relief post-operatively than placebo, with equivalent levels of adverse events.[5] Etoricoxib given at a dose of 120 mg is as effective or even better than other analgesics that are commonly used.[5]

Adverse effects

Like all other NSAIDs, the COX-2 inhibitors too have their share of adverse effects. Fixed drug eruption and generalised erythema,[6] acute generalized exanthematous pustulosis (AGEP),[7] erythema multiforme like eruption[8] and drug induced pretibial erythema[9] are among the reported serious side effects.

Mechanism of action

Like any other selective COX-2 inhibitor ("coxib"), etoricoxib selectively inhibits isoform 2 of the enzyme cyclooxygenase (COX-2). It has approximately 106-fold selectivity for COX-2 inhibition over COX-1.[10] This reduces the generation of prostaglandins (PGs) from arachidonic acid. The clinical relevance of the drug stems from the role of PGs in the inflammation cascade.

Selective COX-2 inhibitors show less activity on COX-1 compared to traditional non-steroidal anti-inflammatory drugs (NSAID). This reduced activity is the cause of reduced gastrointestinal side effects, as demonstrated in several large clinical trials performed with different coxibs.[11][12]

Cardiovascular safety and concerns

Etoricoxib's safety on the gastrointestinal tract and cardiovascular was evaluated in the MEDAL Program consisting of three clinical trials: MEDAL (Multinational Etoricoxib Versus Diclofenac Arthritis Long-term Study), EDGE (Etoricoxib versus Diclofenac Sodium Gastrointestinal Tolerability and Effectiveness) and EDGE II.[13] Pooled analysis from these trials shows that etoricoxib has the same rates of thrombotic cardiovascular events as those of diclofenac, including thrombotic events (1.24 events per 100 patient-years with etoricoxib versus 1.3 events per 100 patient-years with diclofenac), arterial thrombotic events (1.05 events per 100 patient-years with etoricoxib versus 1.10 events per 100 patient-years with diclofenac) and risks of heart attack, stroke and death of vascular cause (0.84 per 100 patient-years with etoricoxib versus 0.87 events per 100 patient-years with diclofenac). Rates of upper gastrointestinal events (ulcer, bleeding, perforation, and obstruction) are in favor of the etoricoxib group (0.67 events per 100 patient-years with etoricoxib versus 0.97 events per 100 patient-years with diclofenac), but rates of complicated upper gastrointestinal events are similar between two groups.[14]

Like rofecoxib's VIGOR trial, the MEDAL Program was also criticized, this time due to Merck's choice of comparator group. In a testimony before the FDA Arthritis Advisory Committee, Sidney M. Wolfe pointed out that unlike the VIGOR trial, in which the active comparator was naproxen, three trials in the MEDAL Program used diclofenac as an active comparator. Wolfe showed that when compared etoricoxib to naproxen, which is a nonselective COX inhibitor, etoricoxib significantly increases the risks of cardiovascular events to such a degree that "are similar to rofecoxib/naproxen comparison", but when compared etoricoxib to diclofenac, which inhibits COX-2 more preferentially and has a worse CV safety profile than placebo, the difference was not statistically significant. He also noted the increase in other cardiac events, such as heart failure and high blood pressure.[15]

References

  1. ^ Anvisa (31 March 2023). "RDC Nº 784 - Listas de Substâncias Entorpecentes, Psicotrópicas, Precursoras e Outras sob Controle Especial" [Collegiate Board Resolution No. 784 - Lists of Narcotic, Psychotropic, Precursor, and Other Substances under Special Control] (in Brazilian Portuguese). Diário Oficial da União (published 4 April 2023). Archived from the original on 3 August 2023. Retrieved 16 August 2023.
  2. ^ "Merck & Co., Inc. (Jobs) Receives Non Approvable Letter from FDA for Arcoxia (etoricoxib)". BioSpace. Retrieved 15 October 2023.
  3. ^ Fischer J, Ganellin CR (2006). Analogue-based Drug Discovery. John Wiley & Sons. p. 522. ISBN 978-3-527-60749-5.
  4. ^ "Arcoxia - Article 6 (12) referral - Annex I, II, III, IV" (PDF). European Medicines Agency. 21 November 2008. Retrieved 15 October 2023.
  5. ^ a b c Clarke R, Derry S, Moore RA (May 2014). "Single dose oral etoricoxib for acute postoperative pain in adults". The Cochrane Database of Systematic Reviews. 2019 (5): CD004309. doi:10.1002/14651858.CD004309.pub4. PMC 6485336. PMID 24809657.
  6. ^ Augustine M, Sharma P, Stephen J, Jayaseelan E (2006). "Fixed drug eruption and generalised erythema following etoricoxib". Indian Journal of Dermatology, Venereology and Leprology. 72 (4): 307–9. doi:10.4103/0378-6323.26732. PMID 16880582.
  7. ^ Mäkelä L, Lammintausta K (2008). "Etoricoxib-induced acute generalized exanthematous pustulosis". Acta Dermato-Venereologica. 88 (2): 200–1. doi:10.2340/00015555-0381. PMID 18311467.
  8. ^ Thirion L, Nikkels AF, Piérard GE (2008). "Etoricoxib-induced erythema-multiforme-like eruption". Dermatology. 216 (3): 227–8. doi:10.1159/000112930. PMID 18182814. S2CID 207645594.
  9. ^ Kumar P (December 2015). "Etoricoxib-induced pretibial erythema and edema". Indian Dermatology Online Journal. 6 (Suppl 1): S47-9. doi:10.4103/2229-5178.171046. PMC 4738517. PMID 26904451.
  10. ^ Riendeau D, Percival MD, Brideau C, Charleson S, Dubé D, Ethier D, et al. (February 2001). "Etoricoxib (MK-0663): preclinical profile and comparison with other agents that selectively inhibit cyclooxygenase-2". The Journal of Pharmacology and Experimental Therapeutics. 296 (2): 558–566. PMID 11160644.
  11. ^ Bombardier C, Laine L, Reicin A, Shapiro D, Burgos-Vargas R, Davis B, et al. (November 2000). "Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. VIGOR Study Group". The New England Journal of Medicine. 343 (21): 1520–8, 2 p following 1528. doi:10.1056/NEJM200011233432103. PMID 11087881.
  12. ^ Cannon CP, Curtis SP, FitzGerald GA, Krum H, Kaur A, Bolognese JA, et al. (November 2006). "Cardiovascular outcomes with etoricoxib and diclofenac in patients with osteoarthritis and rheumatoid arthritis in the Multinational Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) programme: a randomised comparison". Lancet. 368 (9549): 1771–81. doi:10.1016/S0140-6736(06)69666-9. PMID 17113426. S2CID 18464206.
  13. ^ newera-admin (21 November 2011). "MEDAL Study (Multinational Etoricoxib Versus Diclofenac Arthritis Long-Term Study)". London Pain Clinic. Retrieved 15 October 2023.
  14. ^ Cannon CP, Curtis SP, FitzGerald GA, Krum H, Kaur A, Bolognese JA, et al. (MEDAL Steering Committee) (November 2006). "Cardiovascular outcomes with etoricoxib and diclofenac in patients with osteoarthritis and rheumatoid arthritis in the Multinational Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) programme: a randomised comparison". Lancet. 368 (9549): 1771–1781. doi:10.1016/S0140-6736(06)69666-9. PMID 17113426. S2CID 18464206.
  15. ^ "Testimony Concerning Etoricoxib (Arcoxia)". Public Citizen. 12 April 2007. Retrieved 16 October 2023.