General

Genetic Implications:

Pronunciation:
sel-e-kox-ib

Trade Name(s)

• CeleBREX

Ther. Class.
antirheumatics
nonsteroidal anti inflammatory agents

Pharm. Class.
cox 2 inhibitors

Indications

• Relief of signs and symptoms of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and juvenile rheumatoid arthritis.
• Management of acute pain including primary dysmenorrhea.

Action

• Inhibits the enzyme COX-2. This enzyme is required for the synthesis of prostaglandins.
• Has analgesic, anti-inflammatory, and antipyretic properties.

Therapeutic Effect(s):

• Decreased pain and inflammation caused by arthritis or spondylitis.
• Decreased pain.

Pharmacokinetics

Absorption: Bioavailability unknown.

Distribution: 97% bound to plasma proteins; extensive tissue distribution.

Metabolism and Excretion: Mostly metabolized by the hepatic CYP2C9 isoenzyme;  the CYP2C9 enzyme system exhibits genetic polymorphism; poor metabolizers may have significantly ↑ celecoxib concentrations and an ↑ risk of adverse effects; <3% excreted unchanged in urine and feces.

Half-life: 11 hr.

TIME/ACTION PROFILE (pain reduction)

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity;
• Cross-sensitivity may exist with other NSAIDs, including aspirin;
• History of allergic-type reactions to sulfonamides;
• History of asthma, urticaria, or allergic-type reactions to aspirin or other NSAIDs, including the aspirin triad (asthma, nasal polyps, and severe hypersensitivity reactions to aspirin);
• Advanced renal disease;
• Severe hepatic dysfunction;
• Coronary artery bypass graft (CABG) surgery;
• OB:  Should not be used in late pregnancy (may cause premature closure of the ductus arteriosus).

Use Cautiously in:

• Cardiovascular disease or risk factors for cardiovascular disease (may ↑ risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, especially with prolonged use or use of higher doses); avoid use in patients with recent MI or HF;
• Pre-existing renal disease, heart failure, liver dysfunction, concurrent diuretic, or ACE inhibitor therapy (↑ risk of renal impairment);
• Long duration of NSAID use, smoking, alcohol use, advanced liver disease, coagulopathy, and poor general health (↑ risk of GI bleeding);
• Hypertension or fluid retention;
• Renal impairment (may precipitate acute renal failure);
• Serious dehydration (correct deficits before administering);
•  Patients who are known or suspected to be poor CYP2C9 metabolizers (↓ initial dose by 50%);
• Pre-existing asthma;
• Pedi:  Safety not established in children <2 yr or for longer than 6 mo;
• Geri:  ↑ risk of GI bleeding;
• Lactation: Lactation.

Exercise Extreme Caution in:

History of peptic ulcer disease or GI bleeding.

Adverse Reactions/Side Effects

CNS: dizziness, headache, insomnia

CV: HF, MYOCARDIAL INFARCTION, STROKE, THROMBOSIS, edema, hypertension

Derm: EXFOLIATIVE DERMATITIS, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, rash

F and E: hyperkalemia

GI: GI BLEEDING, abdominal pain, diarrhea, dyspepsia, flatulence, nausea

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

• CYP2C9 inhibitors may ↑ levels.
• May ↓ effectiveness of ACE inhibitors, thiazide diuretics, and  furosemide.
•  Fluconazole  ↑ levels (use lowest recommended dosage).
• ↑ risk of GI bleeding with anticoagulants, aspirin, clopidogrel, ticagrelor, prasugrel, corticosteroids, fibrinolytics, SNRIs, or  SSRIs.
• May ↑ serum  lithium  levels.
• Does not inhibit the cardioprotective effect of low-dose  aspirin.

Route/Dosage

PO (Adults):  Osteoarthritis– 200 mg once daily  or  100 mg twice daily.   Rheumatoid arthritis– 100–200 mg twice daily.  Ankylosing spondylitis– 200 mg once daily  or  100 mg twice daily; may ↑ dose after 6 wk to 400 mg daily.  Acute pain, including dysmenorrhea– 400 mg initially, then a 200-mg dose if needed on the first day; then 200 mg twice daily as needed.

Hepatic Impairment 
PO (Adults):  Moderate hepatic impairment (Child-Pugh Class B)– ↓ dose by 50%.

PO (Children ≥2 yr, ≥10 kg–≤25 kg):   Juvenile rheumatoid arthritis– 50 mg twice daily.

PO (Children ≥2 yr, ≥25 kg):   Juvenile rheumatoid arthritis– 100 mg twice daily.

Availability (generic available)

Capsules: 50 mg, 100 mg, 200 mg, 400 mg

Cost: 100 mg $387.18/100, 200 mg $621.67/100, 400 mg $1,576.25/180

In Combination with: amlodipine (Consensi). See combination drugs.

Assessment

• Assess range of motion, degree of swelling, and pain in affected joints before and periodically throughout therapy.
• Assess patient for allergy to sulfonamides, aspirin, or NSAIDs. Patients with these allergies should not receive celecoxib.
• Assess patient for skin rash frequently during therapy. Discontinue at first sign of rash; may be life-threatening. Stevens-Johnson syndrome may develop. Treat symptomatically; may recur once treatment is stopped.

Lab Test Considerations:

May cause ↑ AST and ALT levels.

• May cause hypophosphatemia, hyperkalemia, and ↑ BUN.

Potential Diagnoses

• Impaired physical mobility (Indications) 
• Acute pain (Indications) 

Implementation

• Do not confuse Celebrex (celecoxib) with Celexa (citalopram) or Cerebyx (fosphenytoin).
• PO May be administered without regard to meals. Capsules may be opened and sprinkled on applesauce and ingested immediately with water. Mixture may be stored in the refrigerator for up to 6 hr.

Patient/Family Teaching

• Instruct patient to take celecoxib exactly as directed. Do not take more than prescribed dose. Increasing doses does not appear to increase effectiveness. Use lowest effective dose for shortest period of time. Advise patient to read  Medication Guide  before starting therapy and with each Rx refill in case of changes.
• Advise patient to notify health care professional promptly if signs or symptoms of GI toxicity (abdominal pain, black stools), cardiovascular effects (chest pain, shortness of breath, weakness, slurring of speech), skin rash, unexplained weight gain, or edema occurs. Patients should discontinue celecoxib and notify health care professional if signs and symptoms of hepatotoxicity (nausea, fatigue, lethargy, pruritus, jaundice, upper right quadrant tenderness, flu-like symptoms) occur.
• May cause hypertension. Instruct patient in correct technique for monitoring BP and to notify health care professional if significant changes occur.
• Rep:  Advise patient to notify health care professional if pregnancy is planned or suspected or if breast feeding. Avoid celecoxib after 30 wk of gestation.

Evaluation/Desired Outcomes

• Reduction in joint pain in patients with osteoarthritis.
• Reduction in joint tenderness, pain, and joint swelling in patients with rheumatoid arthritis and juvenile rheumatoid arthritis.
• Decreased pain.
• Decreased pain with dysmenorrhea.