Arcoxia

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Arcoxia on Prescriptsy

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Arcoxia (etoricoxib) is a selective cyclo-oxygenase-2 (COX-2) inhibitor prescribed for the treatment of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, acute gouty arthritis, and short-term management of acute post-operative dental pain.

Available in tablet strengths of 30mg, 60mg, 90mg, and 120mg, Arcoxia provides targeted anti-inflammatory and analgesic effects by selectively blocking the COX-2 enzyme at sites of inflammation while largely sparing the COX-1 enzyme that protects the gastric mucosa.

This selectivity reduces the risk of gastrointestinal ulceration compared with traditional non-selective NSAIDs, though important cardiovascular risks require careful patient selection.

Arthritis and musculoskeletal conditions represent a significant burden of disease in the United Kingdom.

Osteoarthritis alone affects over 8.75 million people who have sought treatment from the NHS, making it the most common joint condition in the UK.

Rheumatoid arthritis affects approximately 400,000 adults, while gout affects around 1 in 40 people and is increasing in prevalence.

NICE guidelines recommend using NSAIDs at the lowest effective dose for the shortest possible duration, with appropriate cardiovascular and gastrointestinal risk assessment prior to prescribing.

This product information has been reviewed by Dr.

Claire Phipps, MBBS MRCGP (GMC 7014359), and provides a detailed clinical overview of Arcoxia, including its mechanism of action, dosing for each licensed indication, cardiovascular and gastrointestinal safety considerations, side effects, and drug interactions relevant to UK prescribing practice.

Important safety information about Arcoxia

Arcoxia carries important cardiovascular and gastrointestinal warnings that must be understood before starting treatment. Three critical safety points:

• Cardiovascular risk: COX-2 inhibitors are associated with a dose-dependent increase in the risk of heart attack and stroke. Arcoxia must not be prescribed to patients with established cardiovascular disease, uncontrolled hypertension (persistent blood pressure above 140/90 mmHg), or congestive heart failure. Blood pressure must be monitored before starting and within the first 2 weeks of treatment.
• Gastrointestinal risk: Although COX-2 selectivity reduces gastrointestinal toxicity, serious GI events (bleeding, ulceration, perforation) can still occur, particularly in elderly patients, those with a history of peptic ulcer disease, and those taking concurrent low-dose aspirin or anticoagulants.
• Skin reactions: Rare but potentially fatal skin reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis) have been reported. Stop Arcoxia immediately and seek emergency medical attention if you develop a new skin rash with blistering, peeling, mouth sores, or mucosal involvement.

If you experience chest pain, shortness of breath, sudden weakness on one side of the body, slurred speech, black tarry stools, or vomiting blood, seek emergency medical attention immediately by calling 999.

Learn more about online GP consultations for routine arthritis medication reviews.

What Arcoxia is and how it works

Etoricoxib belongs to the class of drugs known as selective COX-2 inhibitors (coxibs). Its mechanism of action involves targeted inhibition of the cyclo-oxygenase-2 (COX-2) enzyme:

The two cyclo-oxygenase isoforms have distinct physiological roles.

COX-1 is constitutively expressed in most tissues, including the gastric mucosa, platelets, and kidneys, where it produces protective prostaglandins that maintain the gastric mucosal barrier, support platelet aggregation, and regulate renal blood flow.

COX-2 is induced primarily at sites of inflammation and tissue damage, where it catalyses the production of prostaglandins (particularly PGE2) and thromboxane A2 that mediate pain, swelling, redness, and fever.

Etoricoxib inhibits COX-2 with approximately 106-fold selectivity over COX-1 in human whole blood assays, making it one of the most selective COX-2 inhibitors available.

This selectivity means that at therapeutic doses, etoricoxib substantially reduces inflammatory prostaglandin production while having minimal effect on the prostaglandins that protect the gastric lining.

However, COX-2 also produces prostacyclin (PGI2) in vascular endothelial cells, which inhibits platelet aggregation and promotes vasodilation.

Inhibition of vascular COX-2 without concurrent inhibition of platelet COX-1 (which produces prothrombotic thromboxane A2) creates a prothrombotic imbalance.

This is the pharmacological basis for the cardiovascular risk associated with all COX-2 selective inhibitors.

Etoricoxib is rapidly absorbed after oral administration, reaching peak plasma concentration within approximately 1 hour.

It has an oral bioavailability of approximately 100% and a plasma half-life of approximately 22 hours, supporting once-daily dosing.

It is extensively metabolised in the liver, primarily by CYP3A4, and excreted in the urine as metabolites. The pharmacokinetic profile is not significantly affected by food intake.

Licensed indications for Arcoxia in the UK

Osteoarthritis

Etoricoxib 30mg or 60mg once daily is licensed for the symptomatic treatment of osteoarthritis.

NICE guideline CG177 recommends oral NSAIDs as second-line pharmacological treatment for osteoarthritis when paracetamol and topical NSAIDs provide insufficient relief, and recommends co-prescribing a PPI for gastric protection.

The 30mg dose should be tried first; increase to 60mg only if 30mg provides inadequate symptom control. Use the lowest effective dose for the shortest duration.

Re-evaluate the need for ongoing NSAID therapy at regular intervals (at least annually).

Rheumatoid arthritis and ankylosing spondylitis

Etoricoxib 90mg once daily is licensed for symptomatic relief of rheumatoid arthritis (RA) and ankylosing spondylitis (AS).

In RA, etoricoxib is used alongside disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, not as a replacement. Monitor for interactions between etoricoxib and methotrexate (see Warnings section).

In AS, NSAIDs are a first-line treatment recommended by NICE guideline NG65; etoricoxib provides effective symptom control of spinal pain and morning stiffness.

Acute gouty arthritis

Etoricoxib 120mg once daily for a maximum of 8 days is licensed for the treatment of acute gout flares.

The MEDAL programme and subsequent studies have shown etoricoxib 120mg to provide comparable pain relief to indomethacin 50mg three times daily for acute gout, with significantly fewer gastrointestinal side effects.

Treatment should begin as early as possible after the onset of gout symptoms for maximum efficacy.

Do not use Arcoxia for prophylaxis of gout attacks or for chronic gout management; urate-lowering therapy (allopurinol or febuxostat) is the appropriate long-term strategy.

Acute post-operative dental pain

Etoricoxib 90mg once daily for a maximum of 3 days is licensed for acute dental pain following dental surgery. This is a time-limited indication only. Arcoxia is not licensed for chronic dental pain or temporomandibular joint dysfunction.

Detailed dosing guidance

All doses are taken once daily, swallowed whole with water. The dose depends on the indication and should always be the lowest effective dose for the shortest period:

For osteoarthritis, begin with 30mg once daily. If symptom relief is insufficient after 2 weeks, increase to 60mg once daily. Do not exceed 60mg daily for osteoarthritis.

For rheumatoid arthritis and ankylosing spondylitis, the standard dose is 90mg once daily; do not exceed 90mg daily.

For acute gouty arthritis, take 120mg once daily from the onset of the attack for a maximum of 8 days.

For post-operative dental pain, take 90mg once daily for a maximum of 3 days.

Dose adjustments are required in hepatic and renal impairment. In mild hepatic impairment (Child-Pugh A), the maximum dose across all indications is 60mg daily.

In moderate hepatic impairment (Child-Pugh B), the maximum is 30mg daily, and every-other-day dosing may be considered. Severe hepatic dysfunction is a contraindication.

In moderate renal impairment (CrCl 30-59 mL/min), do not exceed 60mg daily; severe renal impairment (CrCl below 30 mL/min) is a contraindication.

Monitor renal function in all patients on long-term treatment, particularly the elderly and those taking concurrent diuretics or ACE inhibitors.

Cardiovascular risk in detail

The cardiovascular safety of COX-2 inhibitors has been extensively studied following the withdrawal of rofecoxib (Vioxx) in 2004.

The MEDAL programme, the largest prospective randomised NSAID outcomes trial at the time (34,701 patients), compared etoricoxib with diclofenac for cardiovascular safety.

Results showed similar rates of thrombotic cardiovascular events between etoricoxib and diclofenac, confirming that the cardiovascular risk is a class effect shared by all NSAIDs, not unique to coxibs.

NICE, the MHRA, and the BNF recommend the following approach to minimise cardiovascular risk: avoid NSAIDs entirely in patients with established cardiovascular disease; prescribe the lowest effective dose for the shortest possible duration; control blood pressure before and during treatment (target below 140/90 mmHg for most patients); reassess cardiovascular risk factors at each review; and discontinue Arcoxia if blood pressure rises significantly or is persistently uncontrolled.

Etoricoxib causes a dose-related increase in blood pressure.

In clinical trials, mean systolic blood pressure increases of 3-5 mmHg were observed at the 90mg and 120mg doses compared with placebo.

Blood pressure should be monitored before starting treatment, within 2 weeks of initiation, and regularly thereafter.

If blood pressure rises above 140/90 mmHg and cannot be controlled with antihypertensive medication adjustments, Arcoxia should be discontinued.

Gastrointestinal safety considerations

The primary advantage of COX-2 selectivity is reduced gastrointestinal toxicity compared with non-selective NSAIDs.

In the MEDAL programme, etoricoxib was associated with significantly fewer clinical upper GI events (ulcer complications and symptomatic ulcers) than diclofenac.

However, this advantage is substantially reduced or eliminated in patients concurrently taking low-dose aspirin for cardiovascular prophylaxis.

NICE and the BNF recommend co-prescribing a proton pump inhibitor (PPI) with all oral NSAIDs, including COX-2 inhibitors, for patients at increased gastrointestinal risk.

High-risk factors include: age 65 and over, history of peptic ulcer disease or GI bleeding, concurrent anticoagulant or antiplatelet therapy, concurrent systemic corticosteroid use, serious comorbidity including cardiovascular or renal disease, and prolonged NSAID use at maximum dose.

Drug interactions requiring attention

Etoricoxib interacts with several commonly prescribed medications.

The most clinically significant interactions are with warfarin (etoricoxib increases INR by approximately 13%; monitor INR closely when starting, changing dose, or stopping), lithium (etoricoxib can increase plasma lithium levels by approximately 20%; monitor lithium levels), methotrexate (increased risk of methotrexate toxicity; monitor full blood count and renal function), ciclosporin and tacrolimus (enhanced nephrotoxicity), ACE inhibitors and ARBs (reduced antihypertensive effect and increased risk of acute kidney injury in volume-depleted patients), diuretics (reduced diuretic effect and risk of renal impairment), and oral contraceptives containing ethinylestradiol (etoricoxib 120mg increases ethinylestradiol AUC by 50-60%, increasing thrombotic risk; use caution with lower-dose COH).

Prescribing in the UK NHS context

Arcoxia is a prescription-only medicine (POM) in the United Kingdom.

NICE does not specifically recommend or endorse etoricoxib over other NSAIDs but includes it within its recommendations for NSAID use.

The choice between etoricoxib and other NSAIDs (ibuprofen, naproxen, diclofenac) depends on the individual patient's cardiovascular risk, gastrointestinal risk, renal function, and preference for once-daily dosing.

The standard NHS prescription charge in England is 9.90 pounds per item. Prescriptions are free in Scotland, Wales, and Northern Ireland.

Patients with chronic conditions requiring regular prescriptions may benefit from a Prescription Prepayment Certificate.

Repeat prescriptions for Arcoxia should be reviewed at least annually, and GPs should attempt to step down to the lowest effective dose or consider treatment breaks to reassess the need for ongoing NSAID therapy.

Frequently asked questions about Arcoxia

Is Arcoxia safer for the stomach than ibuprofen?

Etoricoxib causes fewer gastrointestinal ulcers and bleeds than non-selective NSAIDs such as ibuprofen or diclofenac, due to its selective COX-2 inhibition that spares the protective COX-1 enzyme in the stomach.

However, this advantage is not absolute: GI events can still occur, and the advantage is reduced if you take concurrent low-dose aspirin.

Your GP may prescribe a PPI alongside Arcoxia for additional gastric protection if you are at higher risk.

Can I take Arcoxia with blood pressure medication?

Arcoxia can reduce the effectiveness of blood pressure medications, particularly ACE inhibitors, ARBs, and diuretics.

If you take antihypertensive drugs, your GP should monitor your blood pressure closely after starting Arcoxia and may need to adjust your blood pressure medication.

Arcoxia must not be started if your blood pressure is persistently above 140/90 mmHg.

How long can I take Arcoxia?

The duration depends on the indication. For acute gout, the maximum is 8 days. For dental pain, the maximum is 3 days.

For osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis, Arcoxia may be used longer-term but should be regularly reviewed (at least annually) by your GP.

The goal is always the lowest effective dose for the shortest necessary duration. Periodic treatment breaks may be attempted to reassess whether ongoing NSAID therapy remains necessary.

Can I drink alcohol while taking Arcoxia?

Moderate alcohol consumption is not specifically contraindicated, but alcohol can increase the risk of gastrointestinal irritation and bleeding when combined with any NSAID.

If you drink alcohol, keep within the UK Chief Medical Officers' low-risk guidelines (no more than 14 units per week, spread across 3 or more days).

Avoid alcohol entirely if you have a history of stomach ulcers or liver problems.

Sources and further reading

• Arcoxia SmPC, Electronic Medicines Compendium (EMC)
• BNF: Etoricoxib
• NICE guideline CG177: Osteoarthritis
• NICE guideline NG65: Spondyloarthritis
• NHS: Arthritis
• MHRA Yellow Card Scheme