Etoricoxib

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Etoricoxib is a prescription-only anti-inflammatory medicine used to treat pain and inflammation associated with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, acute gouty arthritis, and dental pain following oral surgery.

It belongs to a class of drugs known as selective cyclo-oxygenase-2 (COX-2) inhibitors and is available in the UK as tablets in strengths of 30 mg, 60 mg, 90 mg, and 120 mg.

The branded version is Arcoxia, manufactured by Organon (formerly MSD). Generic etoricoxib is also widely available.

Traditional non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, and diclofenac work by inhibiting both COX-1 and COX-2 enzymes.

While effective against pain and inflammation, they also suppress the COX-1-mediated production of prostaglandins that protect the stomach lining, which is why gastrointestinal side effects (ulcers, bleeding) are among the most significant risks of long-term NSAID therapy.

Etoricoxib was developed to address this limitation by selectively targeting COX-2, the enzyme predominantly responsible for inflammation, while largely preserving COX-1 activity.

This page provides a comprehensive clinical overview of etoricoxib for patients in the United Kingdom, covering its mechanism of action, licensed indications, dosing, side effects, cardiovascular and gastrointestinal safety considerations, drug interactions, and how to obtain a prescription through the NHS or an authorised online prescriber.

Important safety information about etoricoxib

Before reading further, note the following essential safety points. Etoricoxib is a prescription-only medicine (POM) and must be used under medical supervision.

• Etoricoxib must not be taken by patients with established heart disease, stroke, peripheral arterial disease, or uncontrolled hypertension (blood pressure consistently above 140/90 mmHg).
• All COX-2 inhibitors carry a dose-dependent risk of cardiovascular events. Use the lowest effective dose for the shortest time necessary.
• Blood pressure should be monitored before starting treatment and at regular intervals during use.
• Etoricoxib should not be used during pregnancy, especially in the third trimester.
• Report any chest pain, sudden neurological symptoms, severe stomach pain, or skin reactions immediately.

Understanding the conditions treated by etoricoxib

Osteoarthritis

Osteoarthritis is the most common form of arthritis in the UK, affecting over 8.5 million people according to the NHS.

It occurs when the protective cartilage that cushions the ends of bones gradually breaks down, leading to pain, stiffness, swelling, and reduced mobility in affected joints.

The knees, hips, hands, and spine are most commonly involved.

NICE guideline NG226 recommends a stepped approach to management, starting with exercise, weight management, and physiotherapy, progressing to paracetamol and topical NSAIDs, and then to oral NSAIDs or COX-2 inhibitors when these measures are insufficient.

Etoricoxib at 30 to 60 mg daily is licensed for osteoarthritis and is recommended as an option where oral NSAID therapy is indicated, particularly for patients at increased risk of gastrointestinal complications.

Rheumatoid arthritis

Rheumatoid arthritis is a chronic autoimmune condition affecting approximately 400,000 adults in the UK.

The immune system attacks the synovial membrane lining the joints, causing persistent inflammation, joint damage, pain, and functional impairment.

Disease-modifying antirheumatic drugs (DMARDs) and biological therapies are the cornerstone of treatment, but NSAIDs and COX-2 inhibitors are commonly used alongside these agents for symptomatic relief of pain and stiffness.

Etoricoxib at 60 to 90 mg daily is licensed for rheumatoid arthritis.

Ankylosing spondylitis

Ankylosing spondylitis is a chronic inflammatory condition primarily affecting the spine and sacroiliac joints, causing back pain, stiffness, and potential spinal fusion over time.

NSAIDs are recommended as first-line pharmacological treatment by NICE (guideline NG65) and are the only drug class shown to reduce both symptoms and radiographic progression in some studies.

Etoricoxib at 60 to 90 mg daily is licensed for this indication.

Acute gouty arthritis

Gout is caused by the deposition of monosodium urate crystals in joints, triggering intense inflammatory episodes characterised by severe pain, redness, warmth, and swelling, most commonly in the first metatarsophalangeal joint (big toe).

In the UK, gout affects approximately 2.5% of adults. Acute attacks are typically treated with NSAIDs, colchicine, or corticosteroids.

Etoricoxib at 120 mg once daily for up to 8 days is licensed for acute gout and provides rapid pain relief comparable to indomethacin, with a more favourable gastrointestinal tolerability profile.

How etoricoxib works: mechanism of action

Prostaglandins are lipid compounds produced from arachidonic acid by the cyclo-oxygenase (COX) enzymes. There are two principal isoforms.

COX-1 is constitutively expressed in most tissues and produces prostaglandins involved in gastric mucosal protection, platelet aggregation, and renal blood flow regulation.

COX-2 is largely an inducible enzyme, upregulated at sites of inflammation, tissue injury, and fever, where it drives the production of prostaglandins that mediate pain, swelling, and pyrexia.

Etoricoxib binds selectively to the active site of COX-2, inhibiting the conversion of arachidonic acid to prostaglandin H2 at inflammatory sites.

At therapeutic doses, it achieves a high degree of COX-2 selectivity (approximately 100-fold selectivity over COX-1 in human whole blood assays).

This selective inhibition results in effective anti-inflammatory and analgesic activity without significantly reducing COX-1-dependent gastric prostaglandin production.

In clinical terms, this translates to a lower incidence of upper gastrointestinal ulceration and bleeding compared with traditional NSAIDs, although the risk is not eliminated entirely.

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

It has a long elimination half-life of approximately 22 hours, allowing convenient once-daily dosing.

It is extensively metabolised in the liver, primarily by CYP3A4, and excreted as inactive metabolites in the urine and faeces.

Clinical evidence and UK prescribing guidance

Etoricoxib has been licensed in the UK since 2002. Its efficacy and safety have been evaluated in large-scale clinical trials across all licensed indications.

The MEDAL programme (Multinational Etoricoxib and Diclofenac Arthritis Long-term study) was the largest NSAID safety trial ever conducted, enrolling over 34,000 patients with osteoarthritis or rheumatoid arthritis and comparing etoricoxib 60 or 90 mg daily with diclofenac 150 mg daily over a mean follow-up of 18 months.

The primary cardiovascular endpoint (thrombotic cardiovascular events) was similar between the two drugs, confirming that etoricoxib does not carry excess cardiovascular risk relative to diclofenac.

Upper gastrointestinal events (ulcer complications, perforations, bleeds, and obstructions) were significantly less common with etoricoxib.

However, etoricoxib was associated with a higher incidence of hypertension, oedema, and cardiac failure-related adverse events.

NICE Technology Appraisal TA27 (updated as TA527) recommends COX-2 inhibitors as an option for patients requiring long-term NSAID therapy who are at increased risk of gastrointestinal adverse effects.

Risk factors include age over 65, history of gastroduodenal ulcer or bleeding, concurrent use of medicines that increase GI risk (anticoagulants, aspirin, corticosteroids, SSRIs), and serious co-morbidity.

The BNF lists etoricoxib alongside celecoxib as the available COX-2 selective inhibitors and advises that the lowest effective dose should be used for the shortest time necessary.

Dosage and administration

Etoricoxib tablets are taken once daily, swallowed whole with water. They may be taken with or without food. The dose depends on the condition being treated.

• Osteoarthritis: 30 mg once daily, increasing to 60 mg once daily if needed.
• Rheumatoid arthritis: 60 mg once daily, increasing to 90 mg once daily if needed.
• Ankylosing spondylitis: 60 mg once daily, increasing to 90 mg once daily if needed.
• Acute gouty arthritis: 120 mg once daily for a maximum of 8 days.
• Post-operative dental pain: 90 mg once daily for a maximum of 3 days.

For chronic conditions, the need for continued treatment should be reassessed at regular intervals. If adequate symptom control is achieved at the lower dose, there is no need to escalate. Dose reduction should be attempted when clinically appropriate.

Special populations

No dose adjustment is required for elderly patients, but cardiovascular and renal function should be monitored closely.

For patients with moderate hepatic impairment (Child-Pugh score 7 to 9), the dose should not exceed 60 mg every other day or 30 mg daily.

Etoricoxib is contraindicated in severe hepatic impairment. No dose adjustment is required for mild renal impairment. Etoricoxib should not be used when creatinine clearance is below 30 mL/min.

Side effects of etoricoxib

Common side effects

The most frequently reported adverse effects in clinical trials include headache, dizziness, raised blood pressure, upper abdominal pain, dyspepsia, flatulence, heartburn, diarrhoea, nausea, and peripheral oedema.

Hypertension is clinically important and occurs in approximately 3 to 5% of patients; blood pressure should be checked before starting treatment and monitored at regular intervals.

Weight gain and fatigue have also been reported commonly.

Uncommon and rare side effects

Uncommon effects include palpitations, atrial fibrillation, visual blurring, tinnitus, mouth ulcers, altered taste, dry mouth, elevated liver enzymes (ALT, AST), muscle cramps, proteinuria, and raised blood urea nitrogen.

Rare effects include hepatitis, anaphylaxis, angioedema, severe skin reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis), interstitial nephritis, and acute renal failure.

Very rarely, cardiovascular thrombotic events including myocardial infarction and stroke have been reported, particularly at higher doses and with prolonged use.

When to seek urgent medical advice

Contact NHS 111 or your GP urgently if you develop significant ankle swelling, persistent headache, unexplained weight gain, or gastrointestinal symptoms such as dark or bloody stools or vomiting blood.

Call 999 or attend A&E if you experience sudden chest pain, weakness or numbness on one side of the body, difficulty speaking, severe allergic reaction (swelling of face, tongue, or throat, difficulty breathing), or widespread blistering of the skin.

Report suspected adverse reactions to the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk .

Warnings and precautions

Cardiovascular safety

All COX-2 inhibitors and non-selective NSAIDs are associated with a small, dose-dependent increase in the risk of cardiovascular thrombotic events (myocardial infarction, stroke).

Etoricoxib is contraindicated in patients with established ischaemic heart disease, cerebrovascular disease, peripheral arterial disease, or uncontrolled hypertension (blood pressure consistently above 140/90 mmHg).

Patients with cardiovascular risk factors (hypertension, diabetes, hyperlipidaemia, smoking, family history) should use etoricoxib only after careful benefit-risk assessment at the lowest effective dose for the shortest duration.

Blood pressure should be monitored before and during treatment. If blood pressure rises significantly, treatment should be reconsidered.

Gastrointestinal safety

While etoricoxib has a lower risk of upper GI complications than traditional NSAIDs, it does not eliminate the risk entirely.

Patients with a history of peptic ulcer disease, gastrointestinal bleeding, or inflammatory bowel disease should be treated with particular caution.

Concurrent use of gastro-protective therapy (a proton pump inhibitor) should be considered for patients at increased GI risk.

The combination of a COX-2 inhibitor with low-dose aspirin negates much of the gastrointestinal advantage over non-selective NSAIDs.

Renal function

Prostaglandins play a role in maintaining renal blood flow, particularly in states of reduced effective circulating volume.

Etoricoxib may cause fluid retention, oedema, and deterioration in renal function, especially in patients with pre-existing renal impairment, heart failure, hepatic cirrhosis, or those taking diuretics, ACE inhibitors, or angiotensin receptor blockers.

Renal function should be monitored during treatment. Etoricoxib is contraindicated in severe renal impairment (creatinine clearance below 30 mL/min).

Hepatic function

Liver function tests should be monitored during treatment.

If signs or symptoms of hepatic dysfunction develop (nausea, fatigue, jaundice, dark urine, pruritus), etoricoxib should be discontinued and liver function formally assessed.

Etoricoxib is contraindicated in severe hepatic impairment (Child-Pugh score 10 or above).

Pregnancy and breastfeeding

Etoricoxib should not be used during pregnancy. In the third trimester, all NSAIDs and COX-2 inhibitors may cause premature closure of the ductus arteriosus, prolonged labour, and oligohydramnios.

Etoricoxib is not recommended during breastfeeding, as it is unknown whether it is excreted in human breast milk.

Drug interactions

Etoricoxib may reduce the antihypertensive effect of ACE inhibitors, angiotensin receptor blockers, beta-blockers, and diuretics. Concurrent use with lithium may increase lithium plasma levels; monitoring is recommended.

Etoricoxib may enhance the anticoagulant effect of warfarin; INR should be checked when starting, changing dose, or stopping etoricoxib. Concurrent use with methotrexate requires monitoring of haematological parameters.

Etoricoxib should not be used with other NSAIDs. Concurrent use with ciclosporin or tacrolimus may increase the risk of nephrotoxicity.

How to get etoricoxib in the UK

Etoricoxib is a prescription-only medicine available on the NHS. Your GP can prescribe it following a clinical assessment, including cardiovascular risk evaluation and blood pressure measurement.

An authorised online prescriber registered with the General Pharmaceutical Council (GPhC) can also prescribe etoricoxib after a structured clinical consultation.

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

Both branded Arcoxia and generic etoricoxib are available, and your pharmacy will dispense whichever is stocked.

Living with arthritis: practical advice alongside etoricoxib

Medication is only one component of arthritis management.

NICE recommends regular exercise, including strengthening, aerobic, and flexibility activities, as a core treatment for osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.

Weight management reduces mechanical stress on weight-bearing joints. Physiotherapy can improve joint function and mobility. Occupational therapy may help with practical adaptations at home and work.

Heat and cold therapy, supportive footwear, and walking aids can provide additional symptom relief.

For patients with rheumatoid arthritis or ankylosing spondylitis, disease-modifying therapy (DMARDs, biologics) remains the primary treatment to control the underlying disease process.

Etoricoxib addresses symptoms but does not alter disease progression. Ensure you attend regular specialist reviews and report any changes in your condition promptly.

When to seek medical advice

Contact your GP or NHS 111 if your pain worsens despite treatment, if you develop new symptoms, or if you experience side effects that are troublesome or persistent.

Seek emergency care (call 999 or attend A&E) if you experience chest pain, sudden neurological symptoms, severe abdominal pain with bleeding, difficulty breathing, or signs of a severe allergic reaction.

Report any adverse reactions via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk .

Sources

• Etoricoxib Film-coated Tablets, Summary of Product Characteristics (EMC)
• Etoricoxib, British National Formulary (BNF)
• NICE NG226: Osteoarthritis in over 16s: diagnosis and management
• NICE NG65: Spondyloarthritis in over 16s: diagnosis and management
• Arthritis, NHS
• MHRA Yellow Card Scheme