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- Parecoxib is available as two formulations:
- 40mg powder for solution for injection vials (pack of 10)
- 40mg powder and solvent for solution for injection vials (pack of 5)
- At the time of writing the guidelines, parecoxib is approximately £5 – £6 per 40mg vial
- In primary care it may take 24-48 hours to obtain supplies given that this is an item not routinely stocked by community pharmacists. Please allow time to obtain supplies to avoid disruptions in symptom management for patients established on parecoxib.
- Sodium chloride is the only diluent to be used with parecoxib injection – if water for injection is used the resulting solution is not isotonic and therefore can cause more site reactions (1).
- Parecoxib should be diluted to a volume of 22ml, to reduce the risk of site reactions (1).
- CSCI Parecoxib has been combined with dexamethasone 500 micrograms in cases of site reactions (3) where the increase in diluent volume or change in site has not helped.
- There is very limited evidence for compatibility of subcutaneous parecoxib with other medications, apart from ranitidine and esomeprazole (7), and ideally should not be combined with any other medications in the CSCI route.
- There is no evidence to limit the duration of usage for parecoxib in the palliative setting. Evidence of parecoxib use in a non-palliative setting has been based on short-term usage in the acute setting (less than 7 days).
- Cautions and relative/absolute contraindications relevant to non-steroidal anti-inflammatory usage apply to parecoxib.
- Contraindications include (2):
- active gastro-intestinal bleeding
- active gastro-intestinal ulceration
- cerebrovascular disease
- following coronary artery bypass graft surgery
- inflammatory bowel disease
- ischaemic heart disease
- mild to severe heart failure
- peripheral arterial disease
- Cautions include (2):
- allergic disorders
- cardiac impairment (NSAIDs may impair renal function)
- coagulation defects
- connective-tissue disorders
- dehydration (risk of renal impairment)
- elderly (risk of serious side-effects and fatalities)
- history of cardiac failure
- history of gastro- intestinal disorders
- hypertension
- may mask symptoms of infection
- oedema
- risk factors for cardiovascular events
- Gastroprotection
- Renal function
- the renal risks of different NSAIDs, including parecoxib, are similar; generally, NSAIDs are not recommended in severe renal impairment. No significant additional risk to renal function has been identified in studies of parecoxib, to date.
- Cardiovascular events
- Both non-selective NSAIDs and COX-2 inhibitors are associated with an increased risk of cardiovascular events in long-term use.
- Parecoxib is also associated with unpredictable but serious skin reactions including angioedema, erythema multiforme and Stevens- Johnson Syndrome. In the event of this, discontinue parecoxib and seek urgent specialist advice.
- In a pooled analysis of 28 placebo-controlled trials of parecoxib and review of post-authorisation safety, for patients receiving up to 7 days of parecoxib administration, the GI ulceration-related events, renal impairment, hypersensitivity reactions, severe cutaneous reactions and cardiovascular embolic/thrombotic events were similar to placebo (2).
Disclaimer
These Guidelines are intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
Whilst SPAGG takes every care to compile accurate information , we cannot guarantee its correctness and completeness, and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.