Atorika^® tabs (Tablets) Instructions for Use

Marketing Authorization Holder

Veropharm, JSC (Russia)

Manufactured By

Canonpharma Production, CJS (Russia)

ATC Code

M01AH05 (Etoricoxib)

Active Substance

Etoricoxib (Rec.INN WHO registered)

Dosage Forms

	Atorika® tabs	Film-coated tablets, 60 mg: 7, 10, 14, 28, or 30 pcs.
		Film-coated tablets, 90 mg: 7, 10, 14, 28, or 30 pcs.
		Film-coated tablets, 120 mg: 7, 10, 14, 28, or 30 pcs.

Dosage Form, Packaging, and Composition

Film-coated tablets green in color, round, biconvex; the cross-section is almost white.

Excipients: calcium hydrogen phosphate – 60 mg, colloidal silicon dioxide – 4 mg, croscarmellose sodium – 4 mg, magnesium stearate – 2 mg, microcrystalline cellulose (type 101) – 70 mg.

Film coating composition Vivacoat PM-7P-182 green – 8 mg [hypromellose (hydroxypropyl methylcellulose) – 4 mg, hypromellose (hydroxypropyl methylcellulose) – 4 mg, yellow iron oxide – 0.0264 mg, brilliant blue – 0.0024 mg, quinoline yellow – 0.192 mg, macrogol (polyethylene glycol) – 0.4 mg, talc – 0.6 mg, titanium dioxide – 2.3792 mg].

7 pcs. – blister packs (1) – cardboard cartons.
7 pcs. – blister packs (2) – cardboard cartons.
7 pcs. – blister packs (4) – cardboard cartons.
10 pcs. – blister packs (1) – cardboard cartons.
10 pcs. – blister packs (3) – cardboard cartons.
14 pcs. – blister packs (1) – cardboard cartons.
14 pcs. – blister packs (2) – cardboard cartons.

Film-coated tablets green in color, round, biconvex; the cross-section is almost white.

Excipients: calcium hydrogen phosphate – 90 mg, colloidal silicon dioxide – 6 mg, croscarmellose sodium – 6 mg, magnesium stearate – 3 mg, microcrystalline cellulose (type 101) – 105 mg.

Film coating composition Vivacoat PM-7P-182 green – 12 mg [hypromellose (hydroxypropyl methylcellulose) – 0.6 mg, hypromellose (hydroxypropyl methylcellulose) – 6 mg, yellow iron oxide – 0.0396 mg, brilliant blue – 0.0036 mg, quinoline yellow – 0.288 mg, macrogol (polyethylene glycol) – 0.6 mg, talc – 0.9 mg, titanium dioxide – 3.5688 mg].

7 pcs. – blister packs (1) – cardboard cartons.
7 pcs. – blister packs (2) – cardboard cartons.
7 pcs. – blister packs (4) – cardboard cartons.
10 pcs. – blister packs (1) – cardboard cartons.
10 pcs. – blister packs (3) – cardboard cartons.
14 pcs. – blister packs (1) – cardboard cartons.
14 pcs. – blister packs (2) – cardboard cartons.

Film-coated tablets green in color, round, biconvex; the cross-section is almost white.

Excipients: calcium hydrogen phosphate – 120 mg, colloidal silicon dioxide – 8 mg, croscarmellose sodium – 8 mg, magnesium stearate – 4 mg, microcrystalline cellulose (type 101) – 140 mg.

Film coating composition Vivacoat PM-7P-182 green – 16 mg [hypromellose (hydroxypropyl methylcellulose) – 0.8 mg, hypromellose (hydroxypropyl methylcellulose) – 8 mg, yellow iron oxide – 0.0528 mg, brilliant blue – 0.0048 mg, quinoline yellow – 0.384 mg, macrogol (polyethylene glycol) – 0.8 mg, talc – 1.2 mg, titanium dioxide – 4.7584 mg].

7 pcs. – blister packs (1) – cardboard cartons.
7 pcs. – blister packs (2) – cardboard cartons.
7 pcs. – blister packs (4) – cardboard cartons.
10 pcs. – blister packs (1) – cardboard cartons.
10 pcs. – blister packs (3) – cardboard cartons.
14 pcs. – blister packs (1) – cardboard cartons.
14 pcs. – blister packs (2) – cardboard cartons.

Clinical-Pharmacological Group

NSAID. Selective COX-2 inhibitor

Pharmacotherapeutic Group

Anti-inflammatory and antirheumatic drugs; non-steroidal anti-inflammatory and antirheumatic drugs; coxibs

Pharmacological Action

NSAID. Selective COX-2 inhibitor, at therapeutic concentrations blocks the formation of prostaglandins and has anti-inflammatory, analgesic, and antipyretic effects. Selective inhibition of COX-2 is accompanied by a reduction in the severity of clinical symptoms associated with the inflammatory process, while there is no effect on platelet function and the gastrointestinal mucosa.

Etoricoxib has a dose-dependent inhibitory effect on COX-2, without affecting COX-1 when used at a daily dose of up to 150 mg. It does not affect the production of prostaglandins in the gastric mucosa and bleeding time. In conducted studies, no decrease in arachidonic acid levels or collagen-induced platelet aggregation was observed.

Pharmacokinetics

After oral administration, it is rapidly absorbed from the gastrointestinal tract. Oral bioavailability is about 100%. After a single 120 mg dose taken by adults on an empty stomach, C_max is 3.6 µg/ml, T_max is 1 hour after administration. Food intake does not significantly affect the extent and rate of absorption of etoricoxib when taken at a dose of 120 mg. However, C_max values decrease by 36% and T_max increases by 2 hours. The mean geometric AUC_0-24 was 37.8 µg × h/ml. The pharmacokinetics of etoricoxib within therapeutic doses are linear.

Plasma protein binding exceeds 92%. V_d at steady state is about 120 L. Etoricoxib crosses the placental and blood-brain barriers.

It is extensively metabolized in the liver, involving cytochrome P450 isoenzymes with the formation of 6-hydroxymethyl-etoricoxib. Five metabolites of etoricoxib have been identified, the main ones being 6-hydroxymethyl-etoricoxib and its derivative, 6-carboxy-acetyl-etoricoxib. The main metabolites do not affect COX-1 and are either inactive or have low activity against COX-2.

It is excreted by the kidneys as metabolites. Less than 1% is excreted unchanged in the urine.

After a single intravenous administration, 70% is excreted by the kidneys, 20% through the intestine, mainly as metabolites. Less than 2% is found unchanged.

Steady state is reached after 7 days with daily administration of a 120 mg dose, with an accumulation factor of about 2, which corresponds to a T_1/2 of about 22 hours. Plasma clearance is approximately 50 ml/min.

In patients with mild hepatic impairment (5-6 points on the Child-Pugh scale), a single dose of etoricoxib 60 mg/day was associated with a 16% increase in AUC compared to healthy subjects.

In patients with moderate hepatic impairment (7-9 points on the Child-Pugh scale) taking the drug at a dose of 60 mg every other day, the AUC value was the same as in healthy subjects taking the drug daily at the same dose.

Hemodialysis had little effect on excretion (dialysis clearance about 50 ml/min).

Indications

Symptomatic treatment of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis; pain and inflammatory symptoms associated with acute gouty arthritis; short-term treatment of pain associated with dental surgery.

ICD codes

Dosage Regimen

Take the drug orally once daily with or without food.

For osteoarthritis, use a dose of 60 mg once daily.

For rheumatoid arthritis, use a dose of 90 mg once daily.

For ankylosing spondylitis, use a dose of 90 mg once daily.

For acute gouty arthritis, use a dose of 120 mg once daily. Limit treatment to a maximum of 8 days for this indication.

For postoperative dental pain, use a dose of 90 mg once daily. Limit treatment to a maximum of 3 days.

Do not exceed the maximum recommended daily dose of 120 mg.

In patients with mild to moderate hepatic impairment (Child-Pugh score 5-9), do not exceed the daily dose of 60 mg.

The drug is contraindicated in patients with severe hepatic impairment (Child-Pugh score greater than 9).

Use the lowest effective dose for the shortest duration necessary to control symptoms.

Assess the need for continued treatment periodically, especially for chronic conditions.

Adverse Reactions

Digestive system frequently – epigastric pain, nausea, diarrhea, dyspepsia, flatulence; sometimes – abdominal distension, belching, increased peristalsis, constipation, dry oral mucosa, gastritis, gastric or duodenal ulcer, irritable bowel syndrome, esophagitis, oral mucosa ulcers, vomiting; very rarely – gastrointestinal ulcers (with bleeding or perforation), hepatitis.

Nervous system frequently – headache, dizziness, weakness; sometimes – taste disturbance, drowsiness, sleep disorders, sensory disturbances, including paresthesia/hyperesthesia, anxiety, depression, concentration disorders; very rarely – hallucinations, confusion.

Sensory organs sometimes – blurred vision, conjunctivitis, tinnitus, vertigo.

Urinary system sometimes – proteinuria; very rarely – renal failure, usually reversible upon drug withdrawal.

Allergic reactions very rarely – anaphylactic/anaphylactoid reactions, including pronounced decrease in blood pressure and shock.

Cardiovascular system frequently – palpitations, increased blood pressure; sometimes – flushing, cerebrovascular accident, atrial fibrillation, congestive heart failure, nonspecific ECG changes, myocardial infarction; very rarely – hypertensive crisis.

Respiratory system sometimes – cough, dyspnea, epistaxis; very rarely – bronchospasm.

Dermatological reactions frequently – ecchymosis; sometimes – facial swelling, skin itching, rash; very rarely – urticaria, Stevens-Johnson syndrome, Lyell’s syndrome.

Infectious complications sometimes – gastroenteritis, upper respiratory tract infections, urinary tract infections.

Musculoskeletal system sometimes – muscle cramps, arthralgia, myalgia.

Metabolism frequently – edema, fluid retention; sometimes – appetite changes, weight gain.

Laboratory tests: frequently – increased activity of liver transaminases; sometimes – increased blood and urine nitrogen, increased CPK activity, decreased hematocrit, decreased hemoglobin, hyperkalemia, leukopenia, thrombocytopenia, increased serum creatinine, increased uric acid; rarely – increased serum sodium.

Other frequently – flu-like syndrome; sometimes – chest pain.

Contraindications

Complete or incomplete combination of bronchial asthma, recurrent nasal or sinus polyposis, and intolerance to acetylsalicylic acid and other NSAIDs (including history).

Erosive and ulcerative changes in the gastric or duodenal mucosa, active gastrointestinal bleeding, cerebrovascular or other bleeding.

Inflammatory bowel diseases (Crohn’s disease, ulcerative colitis) in the acute phase.

Hemophilia and other bleeding disorders.

Severe heart failure (NYHA functional class II-IV).

Severe hepatic insufficiency (more than 9 points on the Child-Pugh scale) or active liver disease.

Severe renal failure (creatinine clearance less than 30 ml/min), progressive kidney disease, confirmed hyperkalemia.

Period after coronary artery bypass surgery; peripheral arterial disease, cerebrovascular disease, clinically significant coronary artery disease.

Persistent arterial hypertension with blood pressure values above 140/90 mm Hg.

Pregnancy, lactation (breastfeeding).

Children and adolescents under 16 years of age.

Hypersensitivity to etoricoxib.

Use in Pregnancy and Lactation

The drug is contraindicated during pregnancy and lactation. Etoricoxib may adversely affect female fertility and is not recommended for women planning pregnancy.

Use in Hepatic Impairment

Contraindicated in severe hepatic insufficiency (more than 9 points on the Child-Pugh scale) or active liver disease. In patients with moderate hepatic insufficiency (5-9 points on the Child-Pugh scale), it is recommended not to exceed the daily dose of 60 mg.

Use in Renal Impairment

Contraindicated in severe renal failure (creatinine clearance less than 30 ml/min), progressive kidney diseases.

Pediatric Use

Contraindicated in children and adolescents under 16 years of age.

Geriatric Use

Use with caution in elderly persons.

Special Precautions

Use with caution in patients with a history of gastrointestinal ulcers, Helicobacter pylori infection, in elderly persons, in patients receiving long-term NSAID therapy, in patients with severe somatic diseases, dyslipidemia/hyperlipidemia, in diabetes mellitus, arterial hypertension, edema and fluid retention, smoking, in patients with creatinine clearance less than 60 ml/min, during concomitant therapy with the following drugs: anticoagulants (e.g., warfarin), antiplatelet agents (e.g., acetylsalicylic acid, clopidogrel), corticosteroids (e.g., prednisolone), selective serotonin reuptake inhibitors (e.g., citalopram, fluoxetine, paroxetine, sertraline), in chronic alcoholism.

During treatment, careful blood pressure monitoring is required during the first 2 weeks and periodically thereafter.

During treatment, liver and kidney function parameters should be regularly monitored. If liver transaminase activity increases 3 times or more above the upper limit of normal, treatment should be discontinued.

Given the increased risk of adverse effects with increasing duration of use, the need for continued treatment and the possibility of dose reduction should be periodically assessed.

Should not be used concomitantly with other NSAIDs.

Effect on ability to drive vehicles and operate machinery

During treatment, caution should be exercised when driving vehicles and engaging in other potentially hazardous activities that require increased concentration and speed of psychomotor reactions. Patients who have experienced episodes of dizziness, drowsiness, or weakness should refrain from activities requiring concentration.

Drug Interactions

In patients receiving warfarin, administration of etoricoxib at a dose of 120 mg/day was associated with an approximately 13% increase in INR and prothrombin time. In patients receiving warfarin or similar drugs, INR should be monitored during the initiation of therapy or changes in the etoricoxib dosing regimen, especially in the first few days.

There are reports that non-selective NSAIDs and selective COX-2 inhibitors can reduce the antihypertensive effect of ACE inhibitors. This interaction should be taken into account when treating patients taking Etoricoxib concomitantly with ACE inhibitors. In patients with impaired renal function (e.g., dehydration or elderly patients), such a combination may worsen functional renal failure.

Etoricoxib can be used concomitantly with low-dose acetylsalicylic acid intended for the prevention of cardiovascular diseases. However, concomitant administration of low-dose acetylsalicylic acid and etoricoxib may lead to an increased incidence of gastrointestinal ulcers and other complications compared with taking etoricoxib alone. After reaching steady state, administration of etoricoxib 120 mg once daily does not affect the antiplatelet activity of low-dose acetylsalicylic acid (81 mg/day). The drug does not replace the prophylactic effect of acetylsalicylic acid in cardiovascular diseases. Cyclosporine and tacrolimus increase the risk of nephrotoxicity during etoricoxib administration.

There is evidence that non-selective NSAIDs and selective COX-2 inhibitors may increase plasma lithium concentrations. This interaction should be taken into account when treating patients taking Etoricoxib concomitantly with lithium.

There is evidence of a 28% increase in plasma methotrexate AUC and a 13% decrease in its renal clearance under the influence of etoricoxib.

Administration of etoricoxib 120 mg with oral contraceptives containing 35 µg ethinyl estradiol and 0.5 to 1 mg norethindrone for 21 days, either simultaneously or 12 hours apart, increases the steady-state AUC_0-24 of ethinyl estradiol by 50-60%. However, norethisterone concentrations are generally not increased to a clinically significant extent. This increase in ethinyl estradiol concentration should be taken into account when selecting an appropriate oral contraceptive for concomitant use with etoricoxib. This fact may lead to an increased incidence of thromboembolism due to increased exposure to ethinyl estradiol.

Etoricoxib does not affect the steady-state AUC_0-24 or elimination of digoxin. However, Etoricoxib increases C_max (on average by 33%), which may be significant in cases of digoxin overdose.

Concomitant administration of etoricoxib and rifampicin (a potent inducer of hepatic metabolism) leads to a 65% decrease in the plasma AUC of etoricoxib. This interaction should be considered when prescribing etoricoxib concomitantly with rifampicin.

Storage Conditions

Store at 2°C (36°F) to 25°C (77°F). Keep in original packaging, protected from light. Keep out of reach of children.

Dispensing Status

Rx Only

Important Safety Information

This information is for educational purposes only and does not replace professional medical advice. Always consult your doctor before use. Dosage and side effects may vary. Use only as prescribed.