Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Nonsteroidal anti-inflammatory drugs (standard or coxibs) - prescribing issues - Management
What monitoring is needed?

  • Enquire about, and manage, adverse effects.
  • Etoricoxib — blood pressure should be checked within 2 weeks of starting etoricoxib, and periodically thereafter.
  • Consider the risks and the response to treatment, and use clinical judgement to decide what must be monitored and how frequently:
    • People with ischaemic heart disease, risk factors for cardiovascular disease, cerebrovascular disease, peripheral vascular disease, and the elderly.
      • Consider monitoring blood pressure, renal function, and features of cardiac failure.
    • Heart failure
      • Consider monitoring features of heart failure (such as body weight, jugular venous distension, crepitations, hepatomegaly, ascites, peripheral oedema) 1–2 weeks after starting or increasing the dose of the NSAID.
      • Consider monitoring renal function (creatinine clearance or estimated glomerular filtration rate) 1–2 weeks after starting or increasing the dose of the NSAID, particularly in people taking an ACE inhibitor, an angiotensin-II receptor antagonist, a diuretic, or in those with impaired renal function.
      • If, at any time, heart failure or renal impairment deteriorates, consider the NSAID as a cause .
    • Hypertension
      • Consider monitoring blood pressure (for example 2–4 weeks after starting or increasing the dose of the NSAID).
      • Blood pressure should be checked within 2 weeks of starting etoricoxib, and periodically thereafter.
      • If, at any time, hypertension control deteriorates, consider the NSAID as a cause.
    • Renal impairment
      • Consider monitoring renal function (creatinine clearance or estimated glomerular filtration rate) 1–2 weeks after starting or increasing the dose of the NSAID, and then regularly thereafter.
      • If, at any time, renal impairment deteriorates, consider the NSAID as a cause.
    • Hepatic impairment
      • Enquire about adverse effects; NSAIDs increase the risk of gastrointestinal bleeding and fluid retention.
  • Check the summary of product characteristics (SPC) for the nonsteroidal anti-inflammatory drug for more specific advice.
  • Consider seeking specialist advice in case of uncertainty.
Basis for recommendation
  • These recommendations are pragmatic advice, and they take into account guidance from the Medicines and Healthcare products Regulatory Agency and the Commission on Human Medicines on the risks of cardiovascular and renal adverse effects [CHM, 2006; MHRA, 2007; MHRA, 2009]:
    • There is evidence on the risks of thrombotic adverse events associated with nonsteroidal anti-inflammatory drugs and evidence on renal adverse events. However, there is no evidence from clinical trials on strategies to monitor people with these risks.
    • The suggested monitoring intervals in people starting and NSAID who also have heart failure, hypertension, or renal impairment, are extrapolated from the monitoring advice for people starting ACE inhibitors. See the CKS topics on Chronic kidney disease - not diabetic, Hypertension - not diabetic, and Heart failure - chronic for further information.

© NHS Institute for Innovation and Improvement