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EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following EC Decision (Sept 2008) SUMMARY OF PRODUCT CHARACTERISTICS
1. NAME OF THE MEDICINAL PRODUCT
<ARCOXIA (see Annex 1)> 30 mg film-coated tablets
<ARCOXIA (see Annex 1)> 60 mg film-coated tablets
<ARCOXIA (see Annex 1)> 90 mg film-coated tablets
<ARCOXIA (see Annex 1)> 120 mg film-coated tablets
[See Annex 1- To be completed nationally]

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each film-coated tablet contains 30, 60, 90 or 120 mg of etoricoxib.
Excipient:
30 mg: lactose 1.4 mg
60 mg: lactose 2.8 mg
90 mg: lactose 4.2 mg
120 mg: lactose 5.6 mg
For a full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Film-coated tablet (tablet).
30 mg Tablets: Blue-green, apple-shaped biconvex tablets <debossed ‘101’ on one side and ‘ACX 30’ on
the other side>.
60 mg Tablets: Dark green, apple-shaped, biconvex tablets <debossed ‘200’ on one side and ‘ARCOXIA
60’ on the other side>.

90 mg Tablets: White, apple-shaped, biconvex tablets <debossed ‘202’ on one side and ‘ARCOXIA 90’
on the other side>.

120 mg Tablets: Pale-green, apple-shaped, biconvex tablets <debossed ‘204’ on one side and ‘ARCOXIA
120’ on the other side>.

4. CLINICAL PARTICULARS
4.1 Therapeutic indications
For the symptomatic relief of osteoarthritis (OA), rheumatoid arthritis (RA), ankylosing spondylitis, and
the pain and signs of inflammation associated with acute gouty arthritis.

EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)
The decision to prescribe a selective COX-2 inhibitor should be based on an assessment of the individual
patient's overall risks (see sections 4.3, 4.4).

4.2 Posology and method of administration

<ARCOXIA> is administered orally and may be taken with or without food. The onset of the effect of the
medicinal product may be faster when <ARCOXIA> is administered without food. This should be
considered when rapid symptomatic relief is needed.
As the cardiovascular risks of etoricoxib may increase with dose and duration of exposure, the shortest
duration possible and the lowest effective daily dose should be used. The patient's need for symptomatic
relief and response to therapy should be re-evaluated periodically, especially in patients with osteoarthritis
(see sections 4.3, 4.4, 4.8 and 5.1).

Osteoarthritis
The recommended dose is 30 mg once daily. In some patients with insufficient relief from symptoms, an
increased dose of 60 mg once daily may increase efficacy. In the absence of an increase in therapeutic
benefit, other therapeutic options should be considered.
Rheumatoid arthritis
The recommended dose is 90 mg once daily.

Acute gouty arthritis
The recommended dose is 120 mg once daily. Etoricoxib 120 mg should be used only for the acute
symptomatic period. In clinical trials for acute gouty arthritis, etoricoxib was given for 8 days.

Ankylosing spondylitis
The recommended dose is 90 mg once daily.
Doses greater than those recommended for each indication have either not demonstrated additional
efficacy or have not been studied. Therefore:
The dose for OA should not exceed 60 mg daily.
The dose for RA and ankylosing spondylitis should not exceed 90 mg daily.
The dose for acute gout should not exceed 120 mg daily, limited to a maximum of 8 days treatment.
Elderly
No dosage adjustment is necessary for elderly patients. As with other drugs, caution should be exercised
in elderly patients (see section 4.4).

Hepatic insufficiency
Regardless of indication, in patients with mild hepatic dysfunction (Child-Pugh score 5-6) a dose of
60 mg once daily should not be exceeded. In patients with moderate hepatic dysfunction (Child-Pugh
score 7-9), regardless of indication, the dose of 60 mg every other day should not be exceeded;
administration of 30 mg once daily can also be considered.
Clinical experience is limited particularly in patients with moderate hepatic dysfunction and caution is
advised. There is no clinical experience in patients with severe hepatic dysfunction (Child-Pugh score
≥10); therefore, its use is contra-indicated in these patients (see sections 4.3, 4.4 and 5.2).
EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following EC Decision (Sept 2008) Renal insufficiency No dosage adjustment is necessary for patients with creatinine clearance ≥30 ml/min (see section 5.2). The use of etoricoxib in patients with creatinine clearance <30 ml/min is contra-indicated (see sections
4.3 and 4.4).

Paediatric patients
Etoricoxib is contra-indicated in children and adolescents under 16 years of age (see section 4.3).

4.3 Contra-indications
Hypersensitivity to the active substance or to any of the excipients (see section 6.1).
Active peptic ulceration or active gastro-intestinal (GI) bleeding.
Patients who have experienced bronchospasm, acute rhinitis, nasal polyps, angioneurotic oedema,
urticaria, or allergic-type reactions after taking acetylsalicylic acid or NSAIDs including COX-2
(cyclooxygenase-2) inhibitors.

Pregnancy and lactation (see sections 4.6 and 5.3).
Severe hepatic dysfunction (serum albumin <25 g/l or Child-Pugh score ≥10).
Estimated renal creatinine clearance <30 ml/min.
Children and adolescents under 16 years of age.
Inflammatory bowel disease.
Congestive heart failure (NYHA II-IV).
Patients with hypertension whose blood pressure is persistently elevated above 140/90mmHg and has not
been adequately controlled
Established ischaemic heart disease, peripheral arterial disease, and/or cerebrovascular disease.

4.4 Special warnings and precautions for use

Gastrointestinal effects
Upper gastrointestinal complications [perforations, ulcers or bleedings (PUBs)], some of them resulting in
fatal outcome, have occurred in patients treated with etoricoxib.
Caution is advised with treatment of patients most at risk of developing a gastrointestinal complication
with NSAIDs; the elderly, patients using any other NSAID or acetylsalicylic acid concomitantly or
patients with a prior history of gastrointestinal disease, such as ulceration and GI bleeding.
There is a further increase in the risk of gastrointestinal adverse effects (gastrointestinal ulceration or
other gastrointestinal complications) when etoricoxib is taken concomitantly with acetylsalicylic acid
(even at low doses). A significant difference in GI safety between selective COX-2 inhibitors +
acetylsalicylic acid vs. NSAIDs + acetylsalicylic acid has not been demonstrated in long-term clinical
trials (see section 5.1).

EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following EC Decision (Sept 2008) Cardiovascular effects Clinical trials suggest that the selective COX-2 inhibitor class of drugs may be associated with a risk of thrombotic events (especially myocardial infarction (MI) and stroke), relative to placebo and some NSAIDs. As the cardiovascular risks of etoricoxib may increase with dose and duration of exposure, the shortest duration possible and the lowest effective daily dose should be used. The patient's need for symptomatic relief and response to therapy should be re-evaluated periodically, especially in patients with osteoarthritis (see sections 4.2, 4.3, 4.8 and 5.1). Patients with significant risk factors for cardiovascular events (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking) should only be treated with etoricoxib after careful consideration (see section 5.1). COX-2 selective inhibitors are not a substitute for acetylsalicylic acid for prophylaxis of cardiovascular thrombo-embolic diseases because of their lack of antiplatelet effect. Therefore antiplatelet therapies should not be discontinued (see sections above, 4.5 and 5.1.). Renal effects Renal prostaglandins may play a compensatory role in the maintenance of renal perfusion. Therefore, under conditions of compromised renal perfusion, administration of etoricoxib may cause a reduction in prostaglandin formation and, secondarily, in renal blood flow, and thereby impair renal function. Patients at greatest risk of this response are those with pre-existing significantly impaired renal function, uncompensated heart failure, or cirrhosis. Monitoring of renal function in such patients should be considered. Fluid retention, oedema and hypertension As with other medicinal products known to inhibit prostaglandin synthesis, fluid retention, oedema and hypertension have been observed in patients taking etoricoxib. All Nonsteroidal Antiinflammatory Drugs (NSAIDs), including etoricoxib, can be associated with new onset or recurrent congestive heart failure. For information regarding a dose related response for etoricoxib see section 5.1. Caution should be exercised in patients with a history of cardiac failure, left ventricular dysfunction, or hypertension and in patients with pre-existing oedema from any other reason. If there is clinical evidence of deterioration in the condition of these patients, appropriate measures including discontinuation of etoricoxib should be taken. Etoricoxib may be associated with more frequent and severe hypertension than some other NSAIDs and selective COX-2 inhibitors, particularly at high doses. Therefore, hypertension should be controlled before treatment with etoricoxib (see section 4.3) and special attention should be paid to blood pressure monitoring during treatment with etoricoxib. Blood pressure should be monitored within two weeks after initiation of treatment and periodically thereafter. If blood pressure rises significantly, alternative treatment should be considered. Hepatic effects Elevations of alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) (approximately three or more times the upper limit of normal) have been reported in approximately 1% of patients in clinical trials treated for up to one year with etoricoxib 30, 60 and 90 mg daily. Any patients with symptoms and/or signs suggesting liver dysfunction, or in whom an abnormal liver function test has occurred, should be monitored. If signs of hepatic insufficiency occur, or if persistently abnormal liver function tests (three times the upper limit of normal) are detected, etoricoxib should be discontinued. EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)
General
If during treatment, patients deteriorate in any of the organ system functions described above, appropriate
measures should be taken and discontinuation of etoricoxib therapy should be considered. Medically
appropriate supervision should be maintained when using etoricoxib in the elderly and in patients with
renal, hepatic, or cardiac dysfunction.

Caution should be used when initiating treatment with etoricoxib in patients with dehydration. It is
advisable to rehydrate patients prior to starting therapy with etoricoxib.
Serious skin reactions, some of them fatal, including exfoliative dermatitis, Stevens-Johnson syndrome,
and toxic epidermal necrolysis, have been reported very rarely in association with the use of NSAIDs and
some selective COX-2 inhibitors during post-marketing surveillance (see section 4.8). Patients appear to
be at highest risk for these reactions early in the course of therapy with the onset of the reaction occurring
in the majority of cases within the first month of treatment. Serious hypersensitivity reactions (such as
anaphylaxis and angioedema) have been reported in patients receiving etoricoxib (see section 4.8). Some
selective COX-2 inhibitors have been associated with an increased risk of skin reactions in patients with a
history of any drug allergy. Etoricoxib should be discontinued at the first appearance of skin rash,
mucosal lesions, or any other sign of hypersensitivity.
Etoricoxib may mask fever and other signs of inflammation.
Caution should be exercised when co-administering etoricoxib with warfarin or other oral anticoagulants
(see section 4.5).
The use of etoricoxib, as with any medicinal product known to inhibit cyclooxygenase / prostaglandin
synthesis, is not recommended in women attempting to conceive (see sections 4.6, 5.1, and 5.3).

<ARCOXIA> tablets contain lactose. Patients with rare hereditary problems of galactose intolerance, the
Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

4.5 Interaction with other medicinal products and other forms of interaction

Pharmacodynamic interactions

Oral anticoagulants: In subjects stabilised on chronic warfarin therapy, the administration of etoricoxib
120 mg daily was associated with an approximate 13% increase in prothrombin time International
Normalised Ratio (INR). Therefore, patients receiving oral anticoagulants should be closely monitored for
their prothrombin time INR, particularly in the first few days when therapy with etoricoxib is initiated or
the dose of etoricoxib is changed (see section 4.4).

Diuretics, ACE inhibitors and Angiotensin II Antagonists:
NSAIDs may reduce the effect of diuretics and
other antihypertensive drugs. In some patients with compromised renal function (e.g. dehydrated patients
or elderly patients with compromised renal function) the co-administration of an ACE inhibitor or
Angiotensin II antagonist and agents that inhibit cyclo-oxygenase may result in further deterioration of
renal function, including possible acute renal failure, which is usually reversible. These interactions
should be considered in patients taking etoricoxib concomitantly with ACE inhibitors or angiotensin II
antagonists. Therefore, the combination should be administered with caution, especially in the elderly.
Patients should be adequately hydrated and consideration should be given to monitoring of renal function
after initiation of concomitant therapy, and periodically thereafter.

EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following EC Decision (Sept 2008) Acetylsalicylic Acid: In a study in healthy subjects, at steady state, etoricoxib 120 mg once daily had no effect on the anti-platelet activity of acetylsalicylic acid (81 mg once daily). Etoricoxib can be used concomitantly with acetylsalicylic acid at doses used for cardiovascular prophylaxis (low-dose acetylsalicylic acid). However, concomitant administration of low-dose acetylsalicylic acid with etoricoxib may result in an increased rate of GI ulceration or other complications compared to use of etoricoxib alone. Concomitant administration of etoricoxib with doses of acetylsalicylic acid above those for cardiovascular prophylaxis or with other NSAIDs is not recommended (see sections 5.1 and 4.4.). Cyclosporin and tacrolimus: Although this interaction has not been studied with etoricoxib, coadministration of cyclosporin or tacrolimus with any NSAID may increase the nephrotoxic effect of cyclosporin or tacrolimus. Renal function should be monitored when etoricoxib and either of these drugs is used in combination. Pharmacokinetic interactions The effect of etoricoxib on the pharmacokinetics of other drugs Lithium: NSAIDs decrease lithium renal excretion and therefore increase lithium plasma levels. If necessary, monitor blood lithium closely and adjust the lithium dosage while the combination is being taken and when the NSAID is withdrawn. Methotrexate: Two studies investigated the effects of etoricoxib 60, 90 or 120 mg administered once daily for seven days in patients receiving once-weekly methotrexate doses of 7.5 to 20 mg for rheumatoid arthritis. Etoricoxib at 60 and 90 mg had no effect on methotrexate plasma concentrations or renal clearance. In one study, etoricoxib 120 mg had no effect, but in the other study, etoricoxib 120 mg increased methotrexate plasma concentrations by 28% and reduced renal clearance of methotrexate by 13%. Adequate monitoring for methotrexate-related toxicity is recommended when etoricoxib and methotrexate are administered concomitantly. Oral contraceptives: Etoricoxib 60 mg given concomitantly with an oral contraceptive containing 35 micrograms ethinyl estradiol (EE) and 0.5 to 1 mg norethindrone for 21 days increased the steady state AUC0-24hr of EE by 37%. Etoricoxib 120 mg given with the same oral contraceptive concomitantly or separated by 12 hours, increased the steady state AUC0-24hr of EE by 50 to 60%. This increase in EE concentration should be considered when selecting an oral contraceptive for use with etoricoxib. An increase in EE exposure can increase the incidence of adverse events associated with oral contraceptives (e.g., venous thrombo-embolic events in women at risk). Hormone Replacement Therapy (HRT): Administration of etoricoxib 120 mg with hormone replacement therapy consisting of conjugated estrogens (0.625 mg PREMARINTM) for 28 days, increased the mean steady state AUC0-24hr of unconjugated estrone (41%), equilin (76%), and 17-β-estradiol (22%). The effect of the recommended chronic doses of etoricoxib (30, 60, and 90 mg) has not been studied. The effects of etoricoxib 120 mg on the exposure (AUC0-24hr) to these estrogenic components of PREMARIN were less than half of those observed when PREMARIN was administered alone and the dose was increased from 0.625 to 1.25 mg. The clinical significance of these increases is unknown, and higher doses of PREMARIN were not studied in combination with etoricoxib. These increases in estrogenic concentration should be taken into consideration when selecting post-menopausal hormone therapy for use with etoricoxib because the increase in oestrogen exposure might increase the risk of adverse events associated with HRT. Prednisone/prednisolone: In drug-interaction studies, etoricoxib did not have clinically important effects on the pharmacokinetics of prednisone/prednisolone. EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)

Digoxin: Etoricoxib 120 mg administered once daily for 10 days to healthy volunteers did not alter the
steady-state plasma AUC0-24hr or renal elimination of digoxin. There was an increase in digoxin Cmax
(approximately 33%). This increase is not generally important for most patients. However, patients at
high risk of digoxin toxicity should be monitored for this when etoricoxib and digoxin are administered
concomitantly.
Effect of etoricoxib on drugs metabolised by sulfotransferases

Etoricoxib is an inhibitor of human sulfotransferase activity, particularly SULT1E1, and has been shown
to increase the serum concentrations of ethinyl estradiol. While knowledge about effects of multiple
sulfotransferases is presently limited and the clinical consequences for many drugs are still being
examined, it may be prudent to exercise care when administering etoricoxib concurrently with other drugs
primarily metabolised by human sulfotransferases (e.g., oral salbutamol and minoxidil).

Effect of etoricoxib on drugs metabolised by CYP isoenzymes

Based on in vitro studies, etoricoxib is not expected to inhibit cytochromes P450 (CYP) 1A2, 2C9, 2C19,
2D6, 2E1 or 3A4. In a study in healthy subjects, daily administration of etoricoxib 120 mg did not alter
hepatic CYP3A4 activity as assessed by the erythromycin breath test.
Effects of other drugs on the pharmacokinetics of etoricoxib


The main pathway of etoricoxib metabolism is dependent on CYP enzymes. CYP3A4 appears to
contribute to the metabolism of etoricoxib in vivo. In vitro studies indicate that CYP2D6, CYP2C9,
CYP1A2 and CYP2C19 also can catalyse the main metabolic pathway, but their quantitative roles have
not been studied in vivo.

Ketoconazole:
Ketoconazole, a potent inhibitor of CYP3A4, dosed at 400 mg once a day for 11 days to
healthy volunteers, did not have any clinically important effect on the single-dose pharmacokinetics of 60
mg etoricoxib (43% increase in AUC).

Rifampicin:
Co-administration of etoricoxib with rifampicin, a potent inducer of CYP enzymes, produced
a 65% decrease in etoricoxib plasma concentrations. This interaction may result in recurrence of
symptoms when etoricoxib is co-administered with rifampicin. While this information may suggest an
increase in dose, doses of etoricoxib greater than those listed for each indication have not been studied in
combination with rifampicin and are therefore not recommended (see section 4.2).

Antacids:
Antacids do not affect the pharmacokinetics of etoricoxib to a clinically relevant extent.

4.6 Pregnancy and lactation

Pregnancy


The use of etoricoxib, as with any drug substance known to inhibit COX-2, is not recommended in
women attempting to conceive.

No clinical data on exposed pregnancies are available for etoricoxib. Studies in animals have shown
reproductive toxicity (see section 5.3). The potential for human risk in pregnancy is unknown. Etoricoxib,
as with other medicinal products inhibiting prostaglandin synthesis, may cause uterine inertia and
EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)
premature closure of the ductus arteriosus during the last trimester. Etoricoxib is contraindicated in
pregnancy (see section 4.3). If a woman becomes pregnant during treatment, etoricoxib must be
discontinued.
Lactation
It is not known whether etoricoxib is excreted in human milk. Etoricoxib is excreted in the milk of
lactating rats. Women who use etoricoxib must not breast feed (see sections 4.3 and 5.3).

4.7 Effects on ability to drive and use machines

No studies on the effect of etoricoxib on the ability to drive or use machines have been performed.
However, patients who experience dizziness, vertigo or somnolence while taking etoricoxib should refrain
from driving or operating machinery.

4.8 Undesirable effects

In clinical trials, etoricoxib was evaluated for safety in 7152 individuals, including 4614 patients with
OA, RA, chronic low back pain or ankylosing spondylitis (approximately 600 patients with OA or RA
were treated for one year or longer).
In clinical studies, the undesirable effects profile was similar in patients with OA or RA treated with
etoricoxib for one year or longer.
In a clinical study for acute gouty arthritis, patients were treated with etoricoxib 120 mg once daily for
eight days. The adverse experience profile in this study was generally similar to that reported in the
combined OA, RA, and chronic low back pain studies.
In a cardiovascular safety outcomes program of pooled data from three active comparator controlled
trials, 17, 412 patients with OA or RA were treated with etoricoxib (60 mg or 90 mg) for a mean duration
of approximately 18 months. The safety data and details from this program are presented in section 5.1.
The following undesirable effects were reported at an incidence greater than placebo in clinical trials in
patients with OA, RA, chronic low back pain or ankylosing spondylitis treated with etoricoxib 30 mg,
60 mg or 90 mg for up to 12 weeks, or in the MEDAL Program studies, or in post-marketing experience:

[Very Common (≥1/10) Common (≥1/100 to <1/10) Uncommon (≥1/1000 to <1/100) Rare (≥1/10,000 to
<1/1,000) Very rare (<1/10,000), not known (cannot be estimated from the available data)]

Infections and infestations:
Uncommon:
gastroenteritis, upper respiratory infection, urinary tract infection.
Immune system disorder:
Very rare:
hypersensitivity reactions, including angioedema, anaphylactic/anaphylactoid reactions
including shock.
Metabolism and nutrition disorders:
Common:
oedema/fluid retention
Uncommon: appetite increase or decrease, weight gain.
Psychiatric disorders:
EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)
Uncommon: anxiety, depression, mental acuity decreased.
Very rare: confusion, hallucinations.
Nervous system disorder:
Common: dizziness, headache.
Uncommon: dysgeusia, insomnia, paresthaesia/hypaesthesia, somnolence.

Eye disorders:
Uncommon:
blurred vision, conjunctivitis.
Ear and labyrinth disorders:
Uncommon:
tinnitus, vertigo.
Cardiac disorders:
Common:
palpitations.
Uncommon: atrial fibrillation, congestive heart failure, non-specific ECG changes, myocardial infarction∗.

Vascular disorders:
Common:
hypertension.
Uncommon: flushing, cerebrovascular accident∗, transient ischaemic attack.
Very rare:
hypertensive crisis.
Respiratory, thoracic and mediastinal disorders:
Uncommon:
cough, dyspnoea, epistaxis.
Very rare
: bronchospasm.
Gastrointestinal disorders:
Common:
gastrointestinal disorders (e.g., abdominal pain, flatulence, heartburn), diarrhea, dyspepsia,
epigastric discomfort, nausea.
Uncommon:
abdominal distention, acid reflux, bowel movement pattern change, constipation, dry mouth,
gastroduodenal ulcer, irritable bowel syndrome, oesophagitis, oral ulcer, vomiting, gastritis.
Very rare:
peptic ulcers including gastrointestinal perforation and bleeding (mainly in the elderly).
Hepatobiliary disorders:

Very rare: hepatitis.

Skin and subcutaneous tissue disorders:
Common:
ecchymosis.
Uncommon:
facial oedema, pruritus, rash.
Very rare:
urticaria, Stevens-Johnson syndrome, toxic epidermal necrolysis.

Musculoskeletal, connective tissue and bone disorders:
Uncommon:
muscular cramp/spasm, musculoskeletal pain/stiffness.

* Based on analyses of long-term placebo and active controlled clinical trials, selective COX-2 inhibitors
have been associated with an increased risk of serious thrombotic arterial events, including myocardial infarction and stroke. The absolute risk increase for such events is unlikely to exceed 1% per year based on existing data (uncommon). EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)

Renal and urinary disorders:
Uncommon:
proteinuria.
Very rare:
renal insufficiency, including renal failure, usually reversible upon discontinuation of
treatment (see section 4.4).

General disorders and administration site conditions:
Common:
asthenia/fatigue, flu-like disease.
Uncommon:
chest pain.
Investigations:
Common:
ALT increased, AST increased.
Uncommon:
blood urea nitrogen increased, creatine phosphokinase increased, haematocrit decreased,
haemoglobin decreased, hyperkalaemia, leukocytes decreased, platelets decreased, serum creatinine
increased, uric acid increased.
Rare:
blood sodium decreased.
The following serious undesirable effects have been reported in association with the use of NSAIDs and
cannot be ruled out for etoricoxib: nephrotoxicity including interstitial nephritis and nephrotic syndrome;
hepatotoxicity including hepatic failure, jaundice and pancreatitis.

4.9 Overdose

In clinical studies, administration of single doses of etoricoxib up to 500 mg and multiple doses up to
150 mg/day for 21 days did not result in significant toxicity. There have been reports of acute overdosage
with etoricoxib, although adverse experiences were not reported in the majority of cases. The most
frequently observed adverse experiences were consistent with the safety profile for etoricoxib (e.g.
gastrointestinal events, cardiorenal events).
In the event of overdose, it is reasonable to employ the usual supportive measures, e.g., remove
unabsorbed material from the GI tract, employ clinical monitoring, and institute supportive therapy, if
required.
Etoricoxib is not dialysable by haemodialysis; it is not known whether etoricoxib is dialysable by
peritoneal dialysis.
5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Anti-inflammatory and antirheumatic products, non-steroids, coxibs, ATC
Code: MO1 AH05
Mechanism of Action
Etoricoxib is an oral, selective cyclo-oxygenase-2 (COX-2) inhibitor within the clinical dose range.
Across clinical pharmacology studies, <ARCOXIA> produced dose-dependent inhibition of COX-2
without inhibition of COX-1 at doses up to 150 mg daily. Etoricoxib did not inhibit gastric prostaglandin
synthesis and had no effect on platelet function.
EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)
Cyclooxygenase is responsible for generation of prostaglandins. Two isoforms, COX-1 and COX-2, have
been identified. COX-2 is the isoform of the enzyme that has been shown to be induced by pro-
inflammatory stimuli and has been postulated to be primarily responsible for the synthesis of prostanoid
mediators of pain, inflammation, and fever. COX-2 is also involved in ovulation, implantation and
closure of the ductus arteriosus, regulation of renal function, and central nervous system functions (fever
induction, pain perception and cognitive function). It may also play a role in ulcer healing. COX-2 has
been identified in tissue around gastric ulcers in man but its relevance to ulcer healing has not been
established.

Efficacy

In patients with osteoarthritis (OA), etoricoxib 60 mg once daily provided significant improvements in
pain and patient assessments of disease status. These beneficial effects were observed as early as the
second day of therapy and maintained for up to 52 weeks. Studies with etoricoxib 30 mg once daily
demonstrated efficacy superior to placebo over a 12 week treatment period (using similar assessments as
the above studies). In a dose ranging study, etoricoxib 60 mg demonstrated significantly greater
improvement than 30 mg for all 3 primary endpoints over 6 weeks of treatment. The 30 mg dose has not
been studied in osteoarthritis of hands.
In patients with rheumatoid arthritis (RA), etoricoxib 90 mg once daily provided significant
improvements in pain, inflammation, and mobility. These beneficial effects were maintained over the 12-
week treatment periods.
In patients experiencing attacks of acute gouty arthritis, etoricoxib 120 mg once daily over an eight-day
treatment period, relieved moderate to extreme joint pain and inflammation comparable to indomethacin
50 mg three times daily. Pain relief was observed as early as four hours after initiation of treatment.
In patients with ankylosing spondylitis, etoricoxib 90 mg once daily provided significant improvements in
spine pain, inflammation, stiffness and function. The clinical benefit of etoricoxib was observed as early
as the second day of therapy after initiation of treatment and was maintained throughout the 52-week
treatment period.
In studies specifically designed to measure the onset of action of etoricoxib, the onset of action occurred
as early as 24 minutes after dosing.
Safety
Multinational Etoricoxib and Diclofenac Arthritis Long-term (MEDAL) Program
The MEDAL Program was a prospectively designed Cardiovascular (CV) Safety Outcomes Program of
pooled data from three randomized, double-blind active comparator controlled trials, the MEDAL study,
EDGE II and EDGE.
The MEDAL Study, was an endpoint driven CV Outcomes study in 17,804 OA and 5,700 RA patients
treated with etoricoxib 60 (OA) or 90 mg (OA and RA) or diclofenac 150 mg daily for a mean period of
20.3 months (maximum of 42.3 months, median 21.3 months). In this trial, only serious adverse events
and discontinuations due to any adverse events were recorded.
The EDGE and EDGE II studies compared the gastrointestinal tolerability of etoricoxib versus diclofenac.
The EDGE study included 7111 OA patients treated with a dose of etoricoxib 90 mg daily (1.5 times the
dose recommended for OA) or diclofenac 150 mg daily for a mean period of 9.1 months (maximum 16.6
EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following EC Decision (Sept 2008) months, median 11.4 months). The EDGE II study included 4086 RA patients treated with etoricoxib 90 mg daily or diclofenac 150 mg daily for a mean period of 19.2 months (maximum 33.1 months, median 24 months). In the pooled MEDAL Program, 34,701 patients with OA or RA were treated for a mean duration of 17.9 months (maximum 42.3 months, median 16.3 months) with approximately 12,800 patients receiving treatment for more than 24 months. Patients enrolled in the Program had a wide range of cardiovascular and gastrointestinal risk factors at baseline. Patients with a recent history of myocardial infarction, coronary artery bypass grafting or percutaneous coronary intervention within 6 months preceding enrollment were excluded. Use of gastroprotective agents and low dose aspirin were permitted in the studies. Overall Safety: There was no significant difference between etoricoxib and diclofenac in the rate of cardiovascular thrombotic events. Cardiorenal adverse events were observed more frequently with etoricoxib than with diclofenac, and this effect was dose-dependent (see specific results below). Gastrointestinal and hepatic adverse events were observed significantly more frequently with diclofenac than etoricoxib. The incidence of adverse experiences in EDGE and EDGE II and of adverse experiences considered serious or resulting in discontinuation in the MEDAL study was higher with etoricoxib than diclofenac. Cardiovascular safety results: The rate of confirmed thrombotic cardiovascular serious adverse events (consisting of cardiac, cerebrovascular, and peripheral vascular events) was comparable between etoricoxib and diclofenac, and data are summarized in the table below. There were no statistically significant differences in thrombotic event rates between etoricoxib and diclofenac across all subgroups analyzed including patient categories across a range of baseline cardiovascular risk. When considered separately, the relative risks for confirmed thrombotic cardiovascular serious adverse events with etoricoxib 60 mg or 90 mg compared with diclofenac 150mg were similar. Table 1: Rates of Confirmed Thrombotic CV Events (Pooled MEDAL Program)
Etoricoxib

Diclofenac
(N=16819)
(N=16483)
Treatment
25836 Patient-
24766 Patient-
Comparison
Rate† (95% CI)
Rate† (95% CI)
Relative Risk
(95% CI)

Confirmed Thrombotic Cardiovascular Serious Adverse Events Per-protocol Confirmed Cerebrovascular Events Per-protocol Confirmed Peripheral Vascular Events Per-protocol EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following EC Decision (Sept 2008) †Events per 100 Patient-Years; CI=confidence interval N=total number of patients included in Per-protocol population Per-protocol: all events on study therapy or within 14 days of discontinuation (excluded: patients who took < 75% of their study medication or took non-study NSAIDs >10% of the time). Intent-to-treat: all confirmed events up to the end of the trial (included patients potentially exposed to non-study interventions following discontinuation of study medication). Total number of patients randomised, n= 17412 on etoricoxib and 17289 on diclofenac.
CV mortality, as well as overall mortality, was similar between the etoricoxib and diclofenac treatment
groups.
Cardiorenal Events:
Approximately 50% of patients enrolled in the MEDAL study had a history of hypertension at baseline.
In the study, the incidence of discontinuations due to hypertension-related adverse events was statistically
significantly higher for etoricoxib than for diclofenac. The incidence of congestive heart failure adverse
events (discontinuations and serious events) occurred at similar rates on etoricoxib 60 mg compared to
diclofenac 150 mg but was higher for etoricoxib 90 mg compared to diclofenac 150 mg (statistically
significant for 90 mg etoricoxib vs. 150 mg diclofenac in MEDAL OA cohort). The incidence of
confirmed congestive heart failure adverse events (events that were serious and resulted in hospitalisation
or a visit to an emergency department) was non-significantly higher with etoricoxib than diclofenac 150
mg, and this effect was dose-dependent. The incidence of discontinuations due to edema-related adverse
events was higher for etoricoxib than diclofenac 150 mg, and this effect was dose-dependent (statistically
significant for etoricoxib 90 mg, but not for etoricoxib 60 mg).

The cardiorenal results for EDGE and EDGE II were consistent with those described for the MEDAL
Study.
In the individual MEDAL Program studies, for etoricoxib (60 mg or 90 mg), the absolute incidence of
discontinuation in any treatment group was up to 2.6% for hypertension, up to 1.9% for edema, and up to
1.1% for congestive heart failure, with higher rates of discontinuation observed with etoricoxib 90 mg
than etoricoxib 60 mg.
MEDAL Program Gastrointestinal Tolerability Results:
A significantly lower rate of discontinuations of treatment for any clinical (e.g., dyspepsia, abdominal
pain, ulcer) GI adverse event was observed with etoricoxib compared with diclofenac within each of the
three component studies of the MEDAL Program. The rates of discontinuations due to adverse clinical GI
events per hundred patient-years over the entire period of study were as follows: 3.23 for etoricoxib and
4.96 for diclofenac in the MEDAL Study; 9.12 with etoricoxib and 12.28 with diclofenac in the EDGE
study; and 3.71 with etoricoxib and 4.81 with diclofenac in the EDGE II study.
MEDAL Program Gastrointestinal Safety Results:
Overall upper GI events were defined as perforations, ulcers and bleeds. The subset of overall upper GI
events considered complicated included perforations, obstructions, and complicated bleeding; the subset
of upper GI events considered uncomplicated included uncomplicated bleeds and uncomplicated ulcers. A
significantly lower rate of overall upper GI events was observed with etoricoxib compared to diclofenac.
There was no significant difference between etoricoxib and diclofenac in the rate of complicated events.
For the subset of upper GI hemorrhage events (complicated and uncomplicated combined), there was no
EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following EC Decision (Sept 2008) significant difference between etoricoxib and diclofenac. The upper GI benefit for etoricoxib compared with diclofenac was not statistically significant in patients taking concomitant low-dose aspirin (approximately 33% of patients). The rates per hundred patient-years of confirmed complicated and uncomplicated upper GI clinical events (perforations, ulcers and bleeds (PUBs)) were 0.67 (95% CI 0.57, 0.77) with etoricoxib and 0.97 (95% CI 0.85, 1.10) with diclofenac, yielding a relative risk of 0.69 (95% CI 0.57, 0.83). The rate for confirmed upper GI events in elderly patients was evaluated and the largest reduction was observed in patients ≥ 75 years of age (1.35 [95% CI 0.94, 1.87] vs. 2.78 [95% CI 2.14, 3.56] events per hundred patient-years for etoricoxib and diclofenac, respectively. The rates of confirmed lower GI clinical events (small or large bowel perforation, obstruction, or hemorrhage, (POBs)) were not significantly different between etoricoxib and diclofenac. MEDAL Program Hepatic Safety Results: Etoricoxib was associated with a statistically significantly lower rate of discontinuations due to hepatic-related adverse experiences than diclofenac. In the pooled MEDAL Program, 0.3% of patients on etoricoxib and 2.7% of patients on diclofenac discontinued due to hepatic-related adverse experiences. The rate per hundred patient-years was 0.22 on etoricoxib and 1.84 for diclofenac (p-value was <0.001 for etoricoxib vs. diclofenac). However, most hepatic adverse experiences in the MEDAL Program were non-serious. Additional Thrombotic Cardiovascular Safety Data In clinical studies excluding the MEDAL Program Studies, approximately 3100 patients were treated with etoricoxib ≥60 mg daily for 12 weeks or longer. There was no discernible difference in the rate of confirmed serious thrombotic cardiovascular events between patients receiving etoricoxib ≥60 mg, placebo, or non-naproxen NSAIDs. However, the rate of these events was higher in patients receiving etoricoxib compared with those receiving naproxen 500 mg twice daily. The difference in antiplatelet activity between some COX-1 inhibiting NSAIDs and selective COX-2 inhibitors may be of clinical significance in patients at risk of thrombo-embolic events. Selective COX-2 inhibitors reduce the formation of systemic (and therefore possibly endothelial) prostacyclin without affecting platelet thromboxane. The clinical relevance of these observations has not been established. Additional Gastrointestinal Safety Data In two 12-week double-blind endoscopy studies, the cumulative incidence of gastroduodenal ulceration was significantly lower in patients treated with etoricoxib 120 mg once daily than in patients treated with either naproxen 500 mg twice daily or ibuprofen 800 mg three times daily. Etoricoxib had a higher incidence of ulceration as compared to placebo. Renal Function Study in the Elderly A randomized, double-blind, placebo-controlled, parallel-group study evaluated the effects of 15 days of treatment of etoricoxib (90 mg), celecoxib (200 mg bid), naproxen (500 mg bid) and placebo on urinary sodium excretion, blood pressure, and other renal function parameters in subjects 60 to 85 years of age on a 200-mEq/day sodium diet. Etoricoxib, celecoxib, and naproxen had similar effects on urinary sodium excretion over the 2 weeks of treatment. All active comparators showed an increase relative to placebo with respect to systolic blood pressures; however, etoricoxib was associated with a statistically significant increase at Day 14 when compared to celecoxib and naproxen (mean change from baseline for systolic blood pressure: etoricoxib 7.7 mmHg, celecoxib 2.4 mmHg, naproxen 3.6 mmHg). EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)

5.2 Pharmacokinetic properties

Absorption
Orally administered etoricoxib is well absorbed. The absolute bioavailability is approximately 100%.
Following 120 mg once-daily dosing to steady state, the peak plasma concentration (geometric mean
Cmax = 3.6 µg/ml) was observed at approximately 1 hour (Tmax) after administration to fasted adults. The
geometric mean area under the curve (AUC0-24hr) was 37.8 µg•hr/ml. The pharmacokinetics of etoricoxib are linear across the clinical dose range. Dosing with food (a high-fat meal) had no effect on the extent of absorption of etoricoxib after administration of a 120-mg dose. The rate of absorption was affected, resulting in a 36% decrease in Cmax and an increase in Tmax by 2 hours. These data are not considered clinically significant. In clinical trials, etoricoxib was administered without regard to food intake. Distribution Etoricoxib is approximately 92% bound to human plasma protein over the range of concentrations of 0.05 to 5 µg/ml. The volume of distribution at steady state (Vdss) was approximately 120 l in humans. Etoricoxib crosses the placenta in rats and rabbits, and the blood-brain barrier in rats. Metabolism Etoricoxib is extensively metabolised with <1% of a dose recovered in urine as the parent drug. The major route of metabolism to form the 6’-hydroxymethyl derivative is catalyzed by CYP enzymes. CYP3A4 appears to contribute to the metabolism of etoricoxib in vivo. In vitro studies indicate that CYP2D6, CYP2C9, CYP1A2 and CYP2C19 also can catalyse the main metabolic pathway, but their quantitative roles in vivo have not been studied. Five metabolites have been identified in man. The principal metabolite is the 6’-carboxylic acid derivative of etoricoxib formed by further oxidation of the 6’-hydroxymethyl derivative. These principal metabolites either demonstrate no measurable activity or are only weakly active as COX-2 inhibitors. None of these metabolites inhibit COX-1. Elimination Following administration of a single 25-mg radiolabeled intravenous dose of etoricoxib to healthy subjects, 70% of radioactivity was recovered in urine and 20% in faeces, mostly as metabolites. Less than 2% was recovered as unchanged drug. Elimination of etoricoxib occurs almost exclusively through metabolism followed by renal excretion. Steady state concentrations of etoricoxib are reached within seven days of once daily administration of 120 mg, with an accumulation ratio of approximately 2, corresponding to a half-life of approximately 22 hours. The plasma clearance after a 25-mg intravenous dose is estimated to be approximately 50 ml/min. Characteristics in patients Elderly: Pharmacokinetics in the elderly (65 years of age and older) are similar to those in the young. Gender: The pharmacokinetics of etoricoxib are similar between men and women. EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)
Hepatic insufficiency: Patients with mild hepatic dysfunction (Child-Pugh score 5-6) administered
etoricoxib 60 mg once daily had an approximately 16% higher mean AUC as compared to healthy
subjects given the same regimen. Patients with moderate hepatic dysfunction (Child-Pugh score 7-9)
administered etoricoxib 60 mg every other day had similar mean AUC to the healthy subjects given
etoricoxib 60 mg once daily; etoricoxib 30 mg once daily has not been studied in this population. There
are no clinical or pharmacokinetic data in patients with severe hepatic dysfunction (Child-Pugh score
≥10). (See sections 4.2 and 4.3.)
Renal insufficiency: The pharmacokinetics of a single dose of etoricoxib 120 mg in patients with
moderate to severe renal insufficiency and patients with end-stage renal disease on hemodialysis were not
significantly different from those in healthy subjects. Hemodialysis contributed negligibly to elimination
(dialysis clearance approximately 50 ml/min). (See sections 4.3 and 4.4.)
Paediatric patients: The pharmacokinetics of etoricoxib in paediatric patients (<12 years old) have not
been studied.
In a pharmacokinetic study (n=16) conducted in adolescents (aged 12 to 17) the pharmacokinetics in
adolescents weighing 40 to 60 kg given etoricoxib 60 mg once daily and adolescents >60 kg given
etoricoxib 90 mg once daily were similar to the pharmacokinetics in adults given etoricoxib 90 mg once
daily. Safety and effectiveness of etoricoxib in paediatric patients have not been established (see section
4.2).
5.3 Preclinical safety data

In preclinical studies, etoricoxib has been demonstrated not to be genotoxic. Etoricoxib was not
carcinogenic in mice. Rats developed hepatocellular and thyroid follicular cell adenomas at >2-times the
daily human dose [90 mg] based on systemic exposure when dosed daily for approximately two years.
Hepatocellular and thyroid follicular cell adenomas observed in rats are considered to be a consequence
of rat-specific mechanism related to hepatic CYP enzyme induction. Etoricoxib has not been shown to
cause hepatic CYP3A enzyme induction in humans.
In the rat, gastrointestinal toxicity of etoricoxib increased with dose and exposure time. In the 14-week
toxicity study etoricoxib caused gastrointestinal ulcers at exposures greater than those seen in man at the
therapeutic dose. In the 53- and 106-week toxicity study, gastrointestinal ulcers were also seen at
exposures comparable to those seen in man at the therapeutic dose. In dogs, renal and gastrointestinal
abnormalities were seen at high exposures.
Etoricoxib was not teratogenic in reproductive toxicity studies conducted in rats at 15 mg/kg/day (this
represents approximately 1.5 times the daily human dose [90 mg] based on systemic exposure). In rabbits,
a treatment related increase in cardiovascular malformations was observed at exposure levels below the
clinical exposure at the daily human dose (90mg). However no treatment-related external or skeletal
foetal malformations were observed. In rats and rabbits, there was a dose dependent increase in post
implantation loss at exposures greater than or equal to 1.5 times the human exposure (see sections 4.3 and
4.6).
Etoricoxib is excreted in the milk of lactating rats at concentrations approximately two-fold those in
plasma. There was a decrease in pup body weight following exposure of pups to milk from dams
administered etoricoxib during lactation.
EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Core:
Calcium hydrogen phosphate (anhydrous)
Croscarmellose sodium
Magnesium stearate
Microcrystalline cellulose
Tablet coating:
Carnauba wax
Lactose monohydrate
Hypromellose
Titanium dioxide (E171)
Triacetin
The 30-, 60- and 120-mg tablets also contain indigo carmine lake (E132) and yellow ferric oxide (E172).
6.2 Incompatibilities

Not applicable.

6.3 Shelf-life
3 years.

6.4 Special precautions for storage
Bottles: Keep the container tightly closed in order to protect from moisture.
Blisters: Store in the original package in order to protect from moisture.
6.5 Nature and contents of container
30 mg
Aluminum/aluminium blisters in packs containing 2, 7, 14, 20, 28 or 98 tablets.

60, 90 and 120 mg
Aluminum/aluminium blisters in packs containing 2, 5, 7, 10, 14, 20, 28, 30, 50, 84, 98 or 100 tablets.
Aluminum/aluminium blisters (unit doses) in packs of 50 or 100 tablets.
White, round, HDPE bottles with a white, polypropylene closure containing 30 tablets and two1-gram
desiccant containers or 90 tablets and one 1-gram desiccant container.
Not all pack sizes may be marketed.

6.6 Special precautions for disposal


No special requirements.
EUSPC-ACX-T-092008 (EUSPC 072008 +approved Referral text following
EC Decision (Sept 2008)

7. MARKETING AUTHORISATION HOLDER
[See Annex 1- To be completed nationally.]
{Name and address}
{tel}
{fax}
{e-mail}
8. MARKETING AUTHORISATION NUMBER
[To be completed nationally.]

9. DATE OF FIRST AUTHORISATION/RENEWAL OF AUTHORISATION

[To be completed nationally.]

10. DATE OF REVISION OF THE TEXT

[To be completed nationally.]


Source: http://next-in.com/arcoxia/downloads/prescribing-infomation-arcoxia.pdf

242454 al jja 2006 copy

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