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CELEBREX (celecoxib)

Health Professional Information

SUMMARY PRODUCT INFORMATION

Route of AdministrationDosage Form / StrengthClinically Relevant Nonmedicinal Ingredients
OralCapsules, 100 mg and 200 mgLactose monohydrate
For a complete listing see DOSAGE FORMS, COMPOSITION AND PACKAGING section.

Indications And Clinical Use

CELEBREX (celecoxib) is indicated for relief of symptoms associated with:

  • Osteoarthritis,
  • Adult Rheumatoid Arthritis, and
  • Ankylosing Spondylitis


CELEBREX is also indicated for the short-term (≤7 days) management of moderate to severe acute pain in adults in conditions such as the following:

  • Musculoskeletal and/or soft tissue trauma including sprains,
  • Postoperative orthopaedic, and
  • Pain following dental extraction


CELEBREX, particularly at doses higher than 200 mg per day, is associated with an increased risk of serious cardiovascular related adverse events (such as myocardial infarction, stroke or thrombotic events, which can be fatal). Doses of CELEBREX >200 mg/day should NOT be used in patients with ischemic heart disease, cerebrovascular disease, patients with congestive heart failure (NYHA II-IV) or patients with risk factors for cardiovascular disease. For patients with an increased risk of developing cardiovascular adverse events, other management strategies that do NOT include the use of NSAIDs, particularly celecoxib, diclofenac, or ibuprofen, should be considered first (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS).

For patients with an increased risk of developing gastrointestinal adverse events, other management strategies that do NOT include the use of NSAIDs, including CELEBREX, should be considered first (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS).

Use of CELEBREX should be limited to the lowest effective dose for the shortest possible duration of treatment in order to minimize the potential risk for cardiovascular or gastrointestinal adverse events (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS).

CELEBREX, as a NSAID, does NOT treat clinical disease or prevent its progression.

CELEBREX, as a NSAID, only relieves symptoms and decreases inflammation for as long as the patient continues to take it.

Geriatrics (>65 years of age):
Evidence from clinical studies and postmarket experience suggests that use in geriatric population is associated with differences in safety (see WARNINGS AND PRECAUTIONS – Special Populations - Geriatrics).

Paediatrics (<18 years of age):
Safety and Efficacy have not been established in the paediatric population (see CONTRAINDICATIONS).

Contraindications

CELEBREX (celecoxib) is contraindicated in:

  • The peri-operative setting of Coronary Artery Bypass Graft Surgery (CABG). Although CELEBREX has NOT been studied in this patient population, a selective COX-2 inhibitor NSAID studied in such a setting has led to an increased incidence of cardiovascular/thromboembolic events, deep surgical infections and sternal wound complications (see CLINICAL TRIALS – Cardiovascular Safety).
  • The third trimester of pregnancy, because of risk of premature closure of the ductus arteriosus and prolonged parturition.
  • Women who are breastfeeding, because of the potential for serious adverse reactions in nursing infants.
  • Severe uncontrolled heart failure.
  • Known hypersensitivity to celecoxib or to any of the components/excipients.
  • Demonstrated allergic-type reactions to sulfonamides.
  • History of asthma, urticaria, or allergic-type reactions after taking Acetylsalicylic Acid (ASA) or other NSAIDs (i.e. complete or partial syndrome of ASA-intolerance - rhinosinusitis, urticaria/angioedema, nasal polyps, asthma). Fatal anaphylactoid reactions have occurred in such individuals. Individuals with the above medical problems are at risk of a severe reaction even if they have taken NSAIDs in the past without any adverse reaction. The potential for cross-reactivity between different NSAIDs must be kept in mind (see WARNINGS AND PRECAUTIONS - Hypersensitivity Reactions - Anaphylactoid Reactions).
  • Active gastric / duodenal / peptic ulcer, active gastrointestinal bleeding.
  • Cerebrovascular bleedings.
  • Inflammatory bowel disease.
  • Severe liver impairment or active liver disease.
  • Severe renal impairment (creatinine clearance <30 mL/min or 0.5 mL/sec) or deteriorating renal disease (individuals with lesser degrees of renal impairment are at risk of deterioration of their renal function when prescribed NSAIDs and must be monitored) (see WARNINGS AND PRECAUTIONS - Renal).
  • Known hyperkalemia (see WARNINGS AND PRECAUTIONS - Renal - Fluid and Electrolyte Balance).
  • Safety and efficacy of CELEBREX have not been established in the paediatric population under 18 years of age.

Warnings And Precautions

Serious Warnings and Precautions

Risk of Cardiovascular (CV) Adverse Events: Ischemic Heart Disease, Cerebrovascular Disease, Congestive Heart Failure (NYHA II-IV) (see WARNINGS AND PRECAUTIONS – Cardiovascular and CLINICAL TRIALS – Cardiovascular Safety).

CELEBREX (celecoxib) is a non-steroidal anti-inflammatory drug (NSAID). CELEBREX (celecoxib), particularly at doses higher than 200 mg per day, is associated with an increased incidence of serious cardiovascular (CV) thrombotic events (such as myocardial infarction and stroke), which can be fatal. This increased risk is comparable to that with high doses of diclofenac (≥150 mg per day) or ibuprofen (≥2400 mg per day). Doses of CELEBREX >200 mg/day should NOT be used in patients with ischemic heart disease (including but NOT limited to acute myocardial infarction, history of myocardial infarction and/or angina), cerebrovascular disease (including but NOT limited to stroke, cerebrovascular accident, transient ischemic attacks and/or amaurosis fugax), congestive heart failure (NYHA II-IV), and/or risk factors for cardiovascular disease.

An increased risk of CV thrombotic events may occur early in the treatment and become higher with the duration of treatment. Patients with CV disease or risk factors for CV disease may be at greater risk (See Cardiovascular in WARNINGS AND PRECAUTIONS). To minimize the potential for an adverse cardiovascular event, the lowest effective dose should be used for the shortest possible duration. For patients with a high risk of developing an adverse cardiovascular event, other management strategies that do NOT include NSAIDs, particularly celecoxib, diclofenac, or ibuprofen, should be considered first.

A meta-analysis of randomized clinical trials comparing several different NSAIDs, concluded that CELEBREX is associated with higher cardiovascular risk when compared with placebo. Large population-based observational studies also support these findings.

Use of NSAIDs, such as CELEBREX, can promote sodium retention in a dose-dependent manner, through a renal mechanism, which can result in increased blood pressure and/or exacerbation of congestive heart failure (see also WARNINGS AND PRECAUTIONS – Renal - Fluid and Electrolyte Balance).

Risk of Gastrointestinal (GI) Adverse Events (see WARNINGS AND PRECAUTIONS – Gastrointestinal (GI) System).

Use of NSAIDs, such as CELEBREX, is associated with an increased incidence of gastrointestinal adverse events (such as peptic/duodenal ulceration, perforation, obstruction and gastrointestinal bleeding).

Risk in Pregnancy: Caution should be exercised in prescribing CELEBREX during the first and second trimesters of pregnancy. CELEBREX is CONTRAINDICATED for use during the third trimester because of risk of premature closure of the ductus arteriosus and uterine inertia (prolonged parturition) (see CONTRAINDICATIONS).

General

Frail or debilitated patients may tolerate side effects less well and therefore special care should be taken in treating this population. To minimize the potential risk for an adverse event, the lowest effective dose should be used for the shortest possible duration. As with other NSAIDs, caution should be used in the treatment of elderly patients who are more likely to be suffering from impaired renal, hepatic or cardiac function. For high-risk patients, alternate therapies that do not involve NSAIDs should be considered.

CELEBREX is NOT recommended for use with other NSAIDs , with the exception of low-dose ASA for cardiovascular prophylaxis, because of the absence of any evidence demonstrating synergistic benefits and the potential for additive adverse reactions (see DRUG INTERACTIONS – Drug-Drug Interactions – Acetylsalicylic Acid (ASA) or other NSAIDs).

Carcinogenesis and Mutagenesis

See TOXICOLOGY – Carcinogenesis and Mutagenesis.

Cardiovascular

CELEBREX is a non-steroidal anti-inflammatory drug (NSAID). CELEBREX, particularly at doses higher than 200 mg per day, is associated with an increased risk of serious cardiovascular (CV) thrombotic events (such as myocardial infarction and stroke), which can be fatal. This increased risk is comparable to that with high doses of diclofenac (≥150 mg per day) or ibuprofen (≥2400 mg per day). Some observational studies showed that the increased risk of the CV thrombotic events began as early as the first weeks of treatment. Such risk increased with duration of NSAID treatment.

The relative increase in risk of serious CV thrombotic events during NSAID treatment appears to be similar in patients with or without CV disease or CV risk factors. However, patients with CV disease or CV risk factors during the treatment had a higher absolute risk of serious CV thrombotic events due to their increased baseline rate.

Some meta-analyses of randomized clinical trials and epidemiological studies suggest that there is an increase in cardiovascular risk at doses greater than 200 mg/day in these populations. Doses of CELEBREX >200 mg/day should NOT be used in patients with ischemic heart disease, cerebrovascular disease, patients with congestive heart failure (NYHA II-IV) or in patients with risk factors for cardiovascular disease (e.g. hypertension, hyperlipidemia, diabetes mellitus and smoking) (see CLINICAL TRIALS – Cardiovascular Safety – Meta-analysis from Chronic Usage Studies).

Caution should be exercised in prescribing CELEBREX to patients with risk factors for cardiovascular disease, cerebrovascular disease or renal disease, such as any of the following (NOT an exhaustive list):

  • Hypertension
  • Dyslipidemia / Hyperlipidemia
  • Diabetes Mellitus
  • Congestive Heart Failure (NYHA I)
  • Coronary Artery Disease (Atherosclerosis)
  • Peripheral Arterial Disease
  • Smoking
  • Creatinine Clearance <60 mL/min or 1 mL/sec
  • Acute myocardial infarction, history of myocardial infarction and/or angina
  • Stroke, cerebrovascular accident, transient ischaemic attacks, and/or amaurosis fugax

Use of NSAIDs, such as CELEBREX, can lead to new hypertension or can worsen pre-existing hypertension, either of which may increase the risk of cardiovascular events as described above. Thus blood pressure should be monitored regularly. Consideration should be given to discontinuing CELEBREX should hypertension either develop or worsen with its use.

Use of NSAIDs, such as CELEBREX, can induce fluid retention and edema, and may exacerbate congestive heart failure, through a renal-mediated mechanism (see WARNINGS AND PRECAUTIONS - Renal - Fluid and Electrolyte Balance).

For patients with a high risk of developing an adverse CV event, other management strategies that do NOT include the use of NSAIDs, particularly celecoxib, diclofenac, or ibuprofen, should be considered first. To minimize the potential risk for an adverse CV event, the lowest effective dose should be used for the shortest possible duration.

One of three randomized clinical trials of about 3 years duration showed a dose-related increase in serious cardiovascular events (mainly myocardial infarction), detectable at doses of CELEBREX 200 mg twice daily or more, compared to placebo.

Endocrine and Metabolism

Corticosteroids: CELEBREX is not a substitute for corticosteroids. It does NOT treat corticosteroid insufficiency. Abrupt discontinuation of corticosteroids may lead to exacerbation of corticosteroid-responsive illness. Patients on prolonged corticosteroid therapy should have their therapy tapered slowly if a decision is made to discontinue corticosteroids (see DRUG INTERACTIONS – Drug-Drug Interactions – Glucocorticoids).

Gastrointestinal (GI) System

Serious GI toxicity (sometimes fatal), such as peptic / duodenal ulceration, inflammation, perforation, obstruction and gastrointestinal bleeding, can occur at any time, with or without warning symptoms, in patients treated with NSAIDs, such as CELEBREX. Minor upper GI problems, such as dyspepsia, commonly occur at any time. Health care providers should remain alert for ulceration and bleeding in patients treated with CELEBREX, even in the absence of previous GI tract symptoms. Most spontaneous reports of fatal GI events are in elderly or debilitated patients and therefore special care should be taken in treating this population. To minimize the potential risk for an adverse GI event, the lowest effective dose should be used for the shortest possible duration. For high-risk patients, alternate therapies that do not involve NSAIDs should be considered (see WARNINGS AND PRECAUTIONS - Special Populations - Geriatrics).

Patients should be informed about the signs and/or symptoms of serious GI toxicity and instructed to discontinue using CELEBREX and seek emergency medical attention if they experience any such symptoms. The utility of periodic laboratory monitoring has NOT been demonstrated, nor has it been adequately assessed. Most patients who develop a serious upper GI adverse event on NSAID therapy have no symptoms. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs, appear to occur in approximately 1% of patients treated for 3 to 6 months, and in about 2% to 4% of patients treated for one year. These trends continue, thus increasing the likelihood of developing a serious GI event at some time during the course of therapy. Even short-term therapy has its risks.

Caution should be taken if prescribing CELEBREX to patients with a prior history of peptic / duodenal ulcer disease and/or gastrointestinal bleeding as these individuals have a greater than 10-fold higher risk for developing a GI bleed when taking NSAID than patients with neither of these risk factors. Other risk factors for GI ulceration and bleeding include the following: Helicobacter pylori infection, increased age, prolonged use of NSAID therapy, excess alcohol intake, smoking, poor general health status or concomitant therapy with any of the following:

  • Anti-coagulants (e.g. warfarin)
  • Anti-platelet agents (e.g. ASA, clopidogrel)
  • Oral corticosteroids (e.g. prednisone)
  • Selective Serotonin Reuptake Inhibitors (SSRIs) (e.g. citalopram, paroxetine, fluoxetine, sertraline)

There is no definitive evidence that the concomitant administration of histamine H2-receptor antagonists and/or antacids will either prevent the occurrence of gastrointestinal side effects or allow the continuation of CELEBREX when and if these adverse reactions appear.

CELEBREX exhibited a low incidence of gastroduodenal ulceration and serious clinically significant GI events within clinical trials (see ADVERSE REACTIONS - Clinical Trial Adverse Drug Reactions). In a prospective long-term outcome study (CLASS), there were no significant differences in the incidence of complicated ulcers between patients who received a higher-than-therapeutic dose of CELEBREX (400 mg BID) for OA and RA, in the presence of concomitant ASA (N = 882 patients), compared to ibuprofen 800mg TID and diclofenac 75mg BID. The incidence of complicated and symptomatic ulcers was lower for CELEBREX than for Ibuprofen in patients not taking ASA. In active-controlled studies, the endoscopic gastroduodenal ulceration rate observed with all doses of CELEBREX was less than what was seen with the NSAID comparator and, in placebo-controlled studies, was similar to that seen with placebo (see CLINICAL TRIALS - Endoscopic Studies).

Genitourinary

Some NSAIDs are associated with persistent urinary symptoms (bladder pain, dysuria, urinary frequency), hematuria or cystitis. The onset of these symptoms may occur at any time after the initiation of therapy with a NSAID. Should urinary symptoms occur, in the absence of alternate explanation, treatment with CELEBREX should be stopped to ascertain if symptoms disappear. This should be done before urological investigations or treatments are carried out.

Hematologic

NSAIDs inhibiting prostaglandin biosynthesis interfere with platelet function to varying degrees; patients who may be adversely affected by such an action, such as those on anti-coagulants or suffering from hemophilia or platelet disorders should be carefully observed when CELEBREX is administered.

CELEBREX does not generally affect platelet counts, prothrombin time (PT), or partial thromboplastin time (PTT), and does not appear to inhibit platelet aggregation at indicated dosages (see CLINICAL TRIALS - Special Studies - Platelets).

Anti-coagulants: The concomitant use of NSAIDs and anticoagulants increases the risk of bleeding and should be done with caution. Concurrent therapy of CELEBREX with anticoagulants requires close monitoring of the international normalized ratio (INR)/anticoagulation (see DRUG INTERACTIONS).

Even with therapeutic INR monitoring, increased bleeding may occur.

In post-marketing experience, serious bleeding events (some of them fatal) have been reported, predominantly in the elderly, in patients receiving CELEBREX concurrently with warfarin or similar agents (see ADVERSE REACTIONS - Post-Market Adverse Drug Reactions).

Anti-platelet Effects: NSAIDs inhibit platelet aggregation and have been shown to prolong bleeding time in some patients. Unlike Acetylsalicylic Acid (ASA), their effect on platelet function is quantitatively less, or of shorter duration, and is reversible. CELEBREX does not appear to inhibit platelet aggregation at indicated dosages (see CLINICAL TRIALS - Special Studies - Platelets).

CELEBREX and other NSAIDs have no proven efficacy as anti-platelet agents and should NOT be used as a substitute for ASA or other anti-platelet agents for prophylaxis of cardiovascular thromboembolic diseases. Anti-platelet therapies (e.g. ASA) should NOT be discontinued. There is some evidence that use of NSAIDs with ASA can markedly attenuate the cardioprotective effects of ASA (see DRUG INTERACTIONS - Drug-Drug Interactions - Acetylsalicylic Acid or other NSAIDs).

Concomitant administration of CELEBREX with low dose ASA increases the risk of GI ulceration and associated complications.

Blood dyscrasias: Blood dyscrasias (such as neutropenia, leukopenia, thrombocytopenia, aplastic anemia and agranulocytosis) associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are rare, but could occur with severe consequences.

Anemia is sometimes seen in patients receiving NSAIDs, including CELEBREX. This may be due to fluid retention, GI blood loss, or an incompletely described effect upon erythropoiesis. Patients on long-term treatment with NSAIDs, including CELEBREX, should have their hemoglobin or hematocrit checked if they exhibit any signs or symptoms of anemia or blood loss.

In controlled clinical trials the incidence of anemia was 0.6% with CELEBREX and 0.4% with placebo. Serious potentially fatal bleeding events have been reported, predominantly in the elderly, in patients receiving CELEBREX concurrently with warfarin or similar agents (see DRUG INTERACTIONS - Drug-Drug Interactions and ADVERSE REACTIONS - Post-Market Adverse Drug Reactions).

Hepatic / Biliary / Pancreatic

As with other NSAIDs, borderline elevations of one or more liver enzyme tests (AST, ALT, alkaline phosphatase) may occur in up to 15% of patients. These laboratory abnormalities may progress, may remain essentially unchanged, or may be transient with continuing therapy.

In controlled clinical trials of CELEBREX, the incidence of borderline elevations of liver tests was 6% for CELEBREX and 5% for placebo, and approximately 0.2% of patients taking CELEBREX and 0.3% of patients taking placebo had notable elevations of ALT and AST.

A patient with symptoms and/or signs suggesting liver dysfunction, or in whom an abnormal liver test has occurred, should be evaluated for evidence of the development of a more severe hepatic reaction while on therapy with CELEBREX. Severe hepatic reactions, including liver necrosis and hepatic failure (with fatal outcomes or requiring liver transplant), fulminant hepatitis (with fatal outcome), cholestatic hepatitis (with fatal outcome) and jaundice have been reported with CELEBREX.

Although such reactions are rare, if abnormal liver tests persist or worsen, if clinical signs and symptoms consistent with liver disease develop (e.g. jaundice), or if systemic manifestations occur (e.g., eosinophilia, associated with rash, etc.), CELEBREX should be discontinued (see CONTRAINDICATIONS).

If there is a need to prescribe this drug in the presence of impaired liver function, it must be done under strict observation.

Hypersensitivity Reactions

Allergies to Sulfonamides: See CONTRAINDICATIONS

Anaphylactoid Reactions: As with NSAIDs in general, anaphylactoid reactions have occurred in patients without known prior exposure to CELEBREX. In post-marketing experience, very rare cases of anaphylactic/anaphylactoid reactions and angioedema have been reported in patients receiving CELEBREX. CELEBREX should NOT be given to patients with the ASA-triad. This symptom complex typically occurs in asthmatic patients who experience rhinitis with or without nasal polyps, or who exhibit severe, potentially fatal bronchospasm after taking ASA or other NSAIDs (see CONTRAINDICATIONS).

ASA-Intolerance: CELEBREX should not be given to patients with the complete or partial syndrome of ASA-intolerance (rhinosinusitis, urticaria/angioedema, nasal polyps, asthma) in whom asthma, anaphylaxis, urticaria/angioedema, rhinitis or other allergic manifestations are precipitated by ASA or other NSAIDs. Fatal anaphylactoid reactions have occurred in such individuals. As well, individuals with the above medical problems are at risk of a severe reaction even if they have taken NSAIDs in the past without any adverse reaction (see CONTRAINDICATIONS).

Cross-Sensitivity: Patients sensitive to one NSAID may be sensitive to any of the other NSAID as well.

Serious Skin Reactions: see WARNINGS AND PRECAUTIONS - Skin

Immune

See WARNINGS AND PRECAUTIONS – Infection – Aseptic Meningitis

Infection

CELEBREX, in common with other NSAIDs, may mask signs and symptoms of an underlying infectious disease.

Aseptic Meningitis: Rarely, with some NSAIDs, the symptoms of aseptic meningitis (stiff neck, severe headaches, nausea and vomiting, fever or clouding of consciousness) have been observed. Patients with autoimmune disorders (systemic lupus erythematosus, mixed connective tissues diseases, etc.) seem to be pre-disposed. Therefore, in such patients, the physician must be vigilant to the development of this complication.

Neurologic

Some patients may experience drowsiness, dizziness, blurred vision, vertigo, tinnitus, hearing loss, insomnia or depression with the use of NSAIDs, such as CELEBREX. If patients experience such adverse reaction(s), they should exercise caution in carrying out activities that require alertness.

Ophthalmologic

Blurred and/or diminished vision has been reported with the use of NSAIDs. If such symptoms develop CELEBREX should be discontinued and an ophthalmologic examination performed. Ophthalmic examination should be carried out at periodic intervals in any patient receiving CELEBREX for an extended period of time.

Peri-Operative Considerations

Coronary Artery Bypass Graft Surgery: See CONTRAINDICATIONS

Psychiatric

See WARNINGS AND PRECAUTIONS – Neurologic

Renal

Long-term administration of NSAIDs to animals has resulted in renal papillary necrosis and other abnormal renal pathology. In humans, there have been reports of acute interstitial nephritis, hematuria, low grade proteinuria and occasionally nephrotic syndrome and acute glomerulonephritis.

Renal insufficiency due to NSAID use is seen in patients with pre-renal conditions leading to reduction in renal blood flow or blood volume. Under these circumstances, renal prostaglandins help maintain renal perfusion and glomerular filtration rate (GFR). In these patients, administration of a NSAID may cause a reduction in prostaglandin synthesis leading to impaired renal function. Patients at greatest risk of this reaction are those with pre-existing renal insufficiency (GFR <60 mL/min or 1 mL/s), dehydrated patients, patients on salt restricted diets, those with congestive heart failure, cirrhosis, liver dysfunction, taking angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, cyclosporin, diuretics, and those who are elderly. In such patients, renal function should be monitored. Serious or life-threatening renal failure has been reported in patients with normal or impaired renal function after short term therapy with NSAIDs. Even patients at risk who demonstrate the ability to tolerate a NSAID under stable conditions may decompensate during periods of added stress (e.g. dehydration due to gastroenteritis). Discontinuation of NSAIDs is usually followed by recovery to the pre-treatment state.

Clinical trials with CELEBREX have shown renal effects similar to those observed with comparator NSAIDs (see CONTRAINDICATIONS).

Caution should be used when initiating treatment with NSAIDS, such as CELEBREX, in patients with considerable dehydration. Such patients should be rehydrated prior to initiation of therapy. Caution is also recommended in patients with pre-existing kidney disease.

Advanced Renal Disease: No information is available from controlled clinical studies regarding the use of CELEBREX in patients with advanced kidney disease. In post-marketing experience, serious renal failure, including the need for dialysis, and fatalities have been reported in patients with impaired renal function. Therefore, treatment with CELEBREX, as with NSAIDs, is not recommended in these patients with advanced renal disease. Kidney function should be monitored, especially in high-risk populations, such as the elderly, patients with cardiovascular disease and diabetes mellitus, as well as in the setting of concomitant use of diuretics and ACE inhibitors (see CONTRAINDICATIONS).

Fluid and Electrolyte Balance: Use of NSAIDs, such as CELEBREX, can promote sodium retention in a dose-dependent manner, which can lead to fluid retention and edema, and consequences of increased blood pressure and exacerbation of congestive heart failure. Thus, caution should be exercised in prescribing CELEBREX in patients with a history of congestive heart failure, compromised cardiac function, hypertension, increased age or other conditions predisposing to fluid retention (see WARNINGS AND PRECAUTIONS – Cardiovascular).

Use of NSAIDs, such as CELEBREX, can increase the risk of hyperkalemia, especially in patients with diabetes mellitus, renal failure, increased age, or those receiving concomitant therapy with adrenergic blockers, angiotensin-converting enzyme inhibitors, angiotensin-II receptor antagonists, cyclosporin, or some diuretics.

Electrolytes should be monitored periodically (see CONTRAINDICATIONS).

Fluid retention has been observed in 2.1% of patients taking CELEBREX in clinical trials (see ADVERSE REACTIONS – Clinical Trials Adverse Drug Reactions). In a prospective long-term outcome study (CLASS), hypertension was observed in 2.0%, 3,1% and 2.0% of patients receiving 400 mg BID CELEBREX (N=3987), 800mg TID ibuprofen (N=1985) and 75mg BID diclofenac (N=1996), respectively. The corresponding rates for edema were: 3.7%, 5.2% and 3.5%, respectively (see ADVERSE REACTIONS - Clinical Trials Adverse Drug Reactions).

Respiratory

ASA-induced asthma is an uncommon but very important indication of ASA and NSAID sensitivity. It occurs more frequently in patients with asthma who have nasal polyps.Cases of pneumonitis, some serious, were identified in patients taking celecoxib.

Sexual Function / Reproduction

The use of CELEBREX, as with any drug known to inhibit cyclooxygenase/prostaglandin synthesis, may impair fertility and is not recommended in women attempting to conceive. Therefore, in women who have difficulties conceiving, or who are undergoing investigation of infertility, withdrawal of CELEBREX should be considered.

Skin

In rare cases, serious skin reactions such as Stevens-Johnson syndrome, toxic epidermal necrolysis, exfoliative dermatitis and erythema multiforme have been associated with the use of some NSAIDs. Because the rate of these reactions is low, they have usually been noted during post-marketing surveillance in patients taking other medications also associated with the potential development of these serious skin reactions. Thus, causality is NOT clear. These reactions are potentially life threatening but may be reversible if the causative agent is discontinued and appropriate treatment instituted. Patients should be advised that if they experience a skin rash they should discontinue their NSAID and contact their physician for assessment and advice, including which additional therapies to discontinue.

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 CELEBREX (see ADVERSE REACTIONS - Post-Market Adverse Drug Reactions). Patients appear to be at higher risk for these events early in the course of therapy: the onset of the event occurring in the majority of cases within the first month of treatment. CELEBREX should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity.

Special Populations

Pregnant Women: CELEBREX is CONTRAINDICATED for use during the third trimester of pregnancy because of risk of premature closure of the ductus arteriosus and the potential to prolong parturition (see TOXICOLOGY). Caution should be exercised in prescribing CELEBREX during the first and second trimesters of pregnancy (see TOXICOLOGY).

NSAIDs including CELEBREX may result in reduction of amniotic fluid volume and even oligohydramnios. Such effects may occur within a few days after treatment initiation and are usually reversible. The rate of oligohydramnios after treatment with some NSAIDs for 2 to 8 weeks was reported as high as 38% or even higher.  NSAIDs were also shown to cause significant reduction in fetal urine production prior to reduction of amniotic fluid volume. Pregnant women on CELEBREX should be closely monitored for amniotic fluid volume.

Inhibition of prostaglandin synthesis may adversely affect pregnancy and/or the embryo-fetal development. Data from epidemiological studies suggest an increased risk of miscarriage and of cardiac malformation after use of a prostaglandin synthesis inhibitor in early pregnancy.

In animals, administration of a prostaglandin synthesis inhibitor has been shown to result in increased pre- and post-implantation loss and embryo-fetal lethality. In addition, increased incidences of various malformations, including cardiovascular, have been reported in animals given a prostaglandin synthesis inhibitor during the organogenetic period.

Nursing Women: See CONTRAINDICATIONS

Paediatrics (<18 years of age): See CONTRAINDICATIONS

Geriatrics (>65 years of age): Patients older than 65 years (referred to in this document as older or elderly) and frail or debilitated patients are more susceptible to a variety of adverse reactions from NSAIDs. The incidence of these adverse reactions increases with dose and duration of treatment. In addition, these patients are less tolerant to ulceration and bleeding. Most reports of fatal GI events are in this population. Older patients are also at risk of lower esophageal injury including ulceration and bleeding. For such patients, consideration should be given a starting dose lower than the one usually recommended, with individual adjustment when necessary and under close supervision.

CELEBREX has been studied in elderly patients. Of the total number of patients who received CELEBREX in clinical trials, more than 3,300 patients (25%) were 65-74 years of age, while approximately 1,300 additional patients (10%) were 75 years and over (see ADVERSE REACTIONS). While the incidence of adverse experiences tended to be higher in elderly patients, no substantial differences in safety and effectiveness were observed between these subjects and younger patients (see WARNINGS AND PRECAUTIONS – Gastrointestinal (GI) System and ADVERSE REACTIONS – Adverse Drug Reaction Overview).

CYP2C9 Poor Metabolizers: Patients who are known, or suspected to be CYP2C9 poor metabolizers based on previous history/experience with other CYP2C9 substrates should be administered celecoxib with caution. CELEBREX should be introduced at half the lowest recommended dose in CYP2C9 poor metabolizers, with a maximum recommended dose of 100 mg daily (see DRUG INTERACTIONS and DOSAGE AND ADMINISTRATION).

Monitoring and Laboratory Tests

Cardiovascular (Hypertension): Blood pressure should be monitored regularly during therapy with CELEBREX.

Hematologic: Patients on long-term treatment with NSAIDs, including CELEBREX, should have their hemoglobin, hematocrit, and blood cell count checked if they exhibit any signs or symptoms of anemia or blood loss.

Concurrent therapy of CELEBREX with anticoagulants requires close monitoring of the international normalized ratio (INR)/anticoagulation.

Hepatic: Patient with symptoms and/or signs of liver dysfunction, or in whom an abnormal liver function test has occurred, should be monitored carefully for evidence of the development of a more severe hepatic reaction while on therapy with CELEBREX. If abnormal liver tests persist or worsen, CELEBREX should be discontinued.

Pregnancy: Pregnant women on CELEBREX should be closely monitored for amniotic fluid volume since CELEBREX may result in reduction of amniotic fluid volume and even oligohydramnios (see Special Populations). CELEBREX is CONTRAINDICATED for use during the third trimester of pregnancy.

Renal: Renal function (serum creatinine and serum urea etc.) should be monitored in high-risk populations, such as the elderly, patients with advanced renal disease, patients with cardiovascular disease and diabetes mellitus, as well as in the setting of concomitant use of diuretics and ACE inhibitors (see CONTRAINDICATIONS). If abnormal renal tests persist or worsen, CELEBREX should be discontinued.

Patients on long-term treatment with NSAIDs, including CELEBREX, should have their electrolytes, such as serum potassium, checked regularly if they exhibit any signs or symptoms of renal disease.

Adverse Reactions

Adverse Drug Reaction Overview

Of the CELEBREX (celecoxib) treated patients in controlled trials, approximately 4,250 were patients with OA, approximately 2,100 were patients with RA, and approximately 1,050 were patients with post-surgical pain. More than 8,500 patients have received a total daily dose of CELEBREX of 200 mg (100 mg BID or 200 mg QD) or more, including more than 400 treated at 800 mg (400 mg BID). Approximately 3,900 patients have received CELEBREX at these doses for 6 months or more; approximately 2,300 of these have received it for 1 year or more and 124 of these have received it for 2 years or more.

CELEBREX has been studied in elderly patients. Of the total number of patients who received CELEBREX in clinical trials, more than 3,300 patients were 65-74 years of age, while approximately 1,300 additional patients were 75 years and over. While the incidence of adverse experiences tended to be higher in elderly patients, no substantial differences in safety and effectiveness were observed between these subjects and younger patients. In GI endoscopy studies involving over 800 elderly patients, the rate of gastroduodenal ulceration was not different in elderly patients compared to the young. Other reported clinical experience has not identified differences in response between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

In clinical studies comparing renal function as measured by the GFR, urea and creatinine, and platelet function as measured by bleeding time and platelet aggregation, the results were not different between elderly and young volunteers.

Clinical Trial Adverse Drug Reactions - New Drug Submission (NDS) Arthritis Trials

Because clinical trials are conducted under very specific conditions the adverse reaction rates observed in the clinical trials may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates.

Table 1 lists all adverse events, regardless of causality, occurring in >2% of patients receiving CELEBREX from 12 controlled studies conducted in patients with osteoarthritis and rheumatoid arthritis that included a placebo and/or a positive control group.

Table 1 Events Occurring in ≥2% of CELEBREX Patients From Original NDS Arthritis Trials
 

Celebrex

100-200mg BID

and 200mg QD

(n=4146)

Placebo

(n=1864)

Naproxen

500mg BID

(n=1366)

Ibuprofen

800mg TID

(n=387)

Diclofenac

75mg BID

(n=345)

Gastrointestinal     

Abdominal pain

4.1%

2.8%

7.7%

9.0%

9.0%

Diarrhea

5.6%

3.8%

5.3%

9.3%

5.8%

Dyspepsia

8.8%

6.2%

12.2%

10.9%

12.8%

Flatulence

2.2%

1.0%

3.6%

4.1%

3.5%

Nausea

3.5%

4.2%

6.0%

3.4%

6.7%

Body as a Whole

     

Back pain

2.8%

3.6%

2.2%

2.6%

0.9%

Peripheral edema

2.1%

1.1%

2.1%

1.0%

3.5%

Injury-accidental

2.9%

2.3%

3.0%

2.6%

3.2%

Central and Peripheral Nervous System

   

Dizziness

2.0%

1.7%

2.6%

1.3%

2.3%

Headache

15.8%

20.2%

14.5%

15.5%

15.4%

Psychiatric

     

Insomnia

2.3%

2.3%

2.9%

1.3%

1.4%

Respiratory

     

Pharyngitis

2.3%

1.1%

1.7%

1.6%

2.6%

Rhinitis

2.0%

1.3%

2.4%

2.3%

0.6%

Sinusitis

5.0%

4.3%

4.0%

5.4%

5.8%

Upper respiratory tract infection

8.1%

6.7%

9.9%

9.8%

9.9%

Skin

     

Rash

2.2%

2.1%

2.1%

1.3%

1.2%

In placebo- or active-controlled clinical trials, the discontinuation rate due to adverse events was 7.1% for patients receiving CELEBREX and 6.1% for patients receiving placebo. Among the most common reasons for discontinuation due to adverse events in the CELEBREX treatment groups were dyspepsia and abdominal pain (cited as reasons for discontinuation in 0.8% and 0.7% of CELEBREX patients, respectively). Among patients receiving placebo, 0.6% discontinued due to dyspepsia and 0.6% withdrew due to abdominal pain.

The adverse event profile from the long-term outcomes trial (at 4- and 2-fold the recommended doses for OA and RA, respectively) is similar to those reported in the arthritis-controlled trials. In the arthritis-controlled trials, the CELEBREX endoscopic gastroduodenal ulceration rate was consistently less than what was seen with the NSAID comparators. In the long-term outcome study however, there was no statistically significant difference for the incidence of complicated ulcers (perforation, obstruction, or bleeding) among the CELEBREX 400 mg BID and NSAID comparators (see CLINICAL TRIALS - Special Studies). The major differences in study design and patient populations preclude direct comparison between the GI endpoint results in the arthritis controlled and the long-term outcome trials.

The incidences of withdrawals due to adverse events and the incidences of selected serious adverse events (i.e., those causing hospitalization or felt to be life-threatening or otherwise medically significant) observed in this trial are shown in Table 2. No significant differences were seen across treatment groups in the incidences of serious adverse events (see Table 2).

Table 2 Summary of Withdrawal and Serious Cardiovascular Adverse Event Data From the CLASS Trial
Incidence Rates (%) in all OA and RA Patients and in Patients Without ASA

All Patients

Celecoxib

400 mg BID

(n=3987)

Diclofenac

75 mg BID

(n=1996)

Ibuprofen
800 mg TID

(n=1985)

All withdrawals

22.4

26.5*

23.0

Withdrawals for GI

Symptoms

12.2

16.6*

13.4

Serious adverse events

6.8

5.6

6.0

Myocardial infarction (fatal and non-fatal)

Deep vein thrombosis

Cardiac failure

Unstable angina

Cerebrovascular disorder

0.5

0.2

0.2

0.2

0.1

0.2

0.3

0.1

0.2

0.3

0.5

0.0

0.5

0.0

0.3

    

Patients Without ASA

(n=3105)

(n=1551)

(n=1573)

All withdrawals

21.2

25.4*

22.5

Withdrawals for GI

Symptoms

11.5

15.4*

13.2

Serious adverse events

5.0

4.2

4.3

Myocardial infarction (fatal and non-fatal)

0.2

0.1

0.1

Deep vein thrombosis

0.2

0.2

0.0

Cardiac failure

0.1

<0.1

0.3

Unstable angina

<0.1

0.0

0.0

Cerebrovascular disorder

<0.1

0.3

0.1

*p<0.05 vs. celecoxib

The following adverse events occurred in 0.1 - 1.9% of patients regardless of causality:

CELEBREX

(100 – 200 mg BID or 200 mg QD)

Gastrointestinal:

Constipation, diverticulitis, dry mouth, dysphagia, eructation, esophagitis, gastritis, gastroenteritis, gastroesophageal reflux, hemorrhoids, hiatal hernia, melena, stomatitis, tenesmus, tooth disorder, vomiting

Cardiovascular:

Aggravated hypertension, angina pectoris, coronary artery disorder, myocardial infarction

General:

Allergy aggravated, allergic reaction, asthenia, chest pain, cyst NOS, edema generalized, face edema, fatigue, fever, hot flushes, influenza-like symptoms, pain, peripheral pain

Resistance Mechanism

Disorders:

Herpes simplex, herpes zoster, infection bacterial, infection fungal, infection soft tissue, infection viral, moniliasis, moniliasis genital, otitis media

Central, Peripheral Nervous System:

Leg cramps, hypertonia, hypoesthesia, migraine, neuralgia, neuropathy, paresthesia, vertigo

Female Reproductive:

Breast fibroadenosis, breast neoplasm, breast pain, dysmenorrhea, menstrual disorder, vaginal hemorrhage, vaginitis

Male Reproductive:

Prostatic disorder

Hearing and Vestibular:

Deafness, ear abnormality, earache, tinnitus

Heart Rate and Rhythm:

Palpitation, tachycardia

Liver and Biliary System:

ALT increased, AST increased, hepatic function abnormal

Metabolic and Nutritional:

Urea increased, CPK increased, diabetes mellitus, hypercholesterolemia, hyperglycemia, hypokalemia, NPN increase, creatinine increased, alkaline phosphatase increased, weight increase

Musculoskeletal:

Arthralgia, arthrosis, bone disorder, fracture accidental, myalgia, neck stiffness, synovitis, tendinitis

Platelets

(bleeding or clotting):

Ecchymosis, epistaxis, thrombocythemia

Psychiatric:

Anorexia, anxiety, appetite increased, depression, nervousness, somnolence

Hemic:

Anemia

Respiratory:

Bronchitis, bronchospasm, bronchospasm aggravated, coughing, dyspnea, laryngitis, pneumonia

Skin and Appendages:

Alopecia, dermatitis, nail disorder, photosensitivity reaction, pruritus, rash erythematous, rash maculopapular, skin disorder, skin dry, sweating increased, urticaria

Application Site Disorders:

Cellulitis, dermatitis contact, injection site reaction, skin nodule

Special Senses:

Taste perversion

Urinary System:

Albuminuria, cystitis, dysuria, hematuria, micturition frequency, renal calculus, urinary incontinence, urinary tract infection

Vision:

Blurred vision, cataract, conjunctivitis, eye pain, glaucoma

Adverse Events From Ankylosing Spondylitis Studies

A total of 896 patients were treated with CELEBREX in placebo- and active-controlled ankylosing spondylitis studies for a maximum duration of 12 weeks. CELEBREX was also studied in one long-term open label extension study up to 2 years in 215 patients with ankylosing spondylitis. The average daily dose was 200 mg. The types of adverse events reported in the ankylosing spondylitis studies were generally similar to those reported in the arthritis studies. The percentage of patients with hypertension (6.1%) and serious GI adverse events (3.7%) in the 2­year, open­label extension study, were greater than those reported in the 12­week studies, respectively of 0.7% and 0.0%. The most common GI disorders reported in the 2-year extension study compared to those reported in the 12­week studies include Diarrhea (15.0% vs. 4.5%), Abdominal Pain upper (13.6 % vs. 3.8%), Dyspepsia (9.8% vs. 3.7%), Nausea (5.6% vs. 2.8%) and Abdominal Pain (5.6% vs. 1.5%). The percentage of patients with cardio-vascular events (1.4%) in the 2-year, open-label extension study was similar to that observed in the CLASS trials.

Adverse Events From Analgesia and Dysmenorrhea Studies

Approximately 1,700 patients were treated with CELEBREX in analgesia and dysmenorrhea studies. All patients in post-oral surgery pain studies received a single dose (up to 400 mg) of study medication. Doses up to 600 mg/day of CELEBREX were studied in primary dysmenorrhea and post-orthopaedic surgery pain studies. The types of adverse experiences in the analgesia and dysmenorrhea studies were similar to those reported in arthritis studies. The only new adverse event reported was alveolar osteitis (dry socket) in the post-oral surgery pain studies.

In approximately 700 patients treated with CELEBREX in the post-general and orthopaedic surgery pain studies, the most commonly reported adverse experiences were nausea, vomiting, headache, dizziness and fever.

Other serious adverse reactions which occur rarely (estimated <0.1%) regardless of causality: the following adverse events have occurred rarely in patients taking CELEBREX.

Cardiovascular:

Syncope, congestive heart failure, ventricular fibrillation, pulmonary embolism, cerebrovascular accident, peripheral gangrene, thrombophlebitis

Gastrointestinal:

Intestinal obstruction, intestinal perforation, gastrointestinal bleeding,  colitis with bleeding, esophageal perforation, pancreatitis, cholelithiasis, ileus

Hemic and

Lymphatic:

Thrombocytopenia

Liver and Biliary System:

Cholelithiasis, hepatitis, jaundice, liver failure

Metabolic:

Hypoglycemia

Nervous System:

Ataxia

Renal:

Acute renal failure

General:

Sepsis, sudden death

Serious Cardiovascular Adverse Events: Long-term Studies Involving Patients with Sporadic Adenomatous Polyps

Two studies involving patients with sporadic adenomatous polyps were conducted with celecoxib: the APC trial (Adenoma Prevention with Celecoxib) and the PreSAP trial (Prevention of Colorectal Sporadic Adenomatous Polyps). In the APC trial, there was a dose-related increase in the composite endpoint of cardiovascular death, myocardial infarction, or stroke (adjudicated) with celecoxib compared to placebo over 3 years of treatment. The PreSAP trial did not demonstrate a statistically significant increased risk for the same composite endpoint, as shown below:

Serious Cardiovascular Adverse Events in the APC and PreSAP Trials

Number (%) of Subjects [Hazards Ratioa (95% Confidence Interval) Compared to Placebo]

 

APC Trial

PreSAP Trial

 

Placebo

N = 679

Celecoxib 200 mg BID

N = 685

Celecoxib 400 mg BID

N = 671

Placebo

N = 628

Celecoxib 400 mg QD

N = 933

Adjudicated Endpointb

      

CV death              

1 (0.1)

5 (0.7)

[4.9 (0.6, 42.2)]

6 (0.9)

[6.2 (0.7, 51.4)]

4 (0.6)

4 (0.4)

[0.7 (0.2, 2.7)]

 

 

  

 

 

CV death or MI  

4 (0.6)

14 (2.0)

[3.5 (1.1, 10.6)]

15 (2.2)

[3.9 (1.3, 11.7)]

7 (1.1)

13 (1.4)

[1.3 (0.5, 3.2)]

 

 

  

 

 

CV death, MI, or stroke (APTC endpoint)

6 (0.9)

17 (2.5)

[2.8 (1.1, 7.2)]

20 (3.0)

[3.4 (1.4, 8.5)]

12 (1.9)

21 (2.3)

[1.2 (0.6, 2.4)]

 

 

  

 

 

BID = Twice daily; QD = Once daily; N = Number of subjects treated; CV = Cardiovascular; MI = Myocardial infarction; APTC = Antiplatelet Trialists’ Collaboration; HF = Heart failure.

a     Hazards ratios are based on event rates per subject-year of exposure to study medication.

b    Includes only serious adverse events, for all randomized subjects, adjudicated and categorized according to a pre‑specified scheme by an independent Cardiovascular Safety Committee blinded to randomized treatment assignments.

Investigator Reports of Adverse Reaction from Long-term, Placebo-controlled Polyp Prevention Studies

Indications and dosages of the PreSAP and APC trials are not approved in Canada. Exposure to CELEBREX in the APC and PreSAP trials was 400 to 800 mg daily for up to 3 years. Among adverse reactions that occurred in higher percentages of patients than in the arthritis pre- marketing trials (treatment durations up to 12 weeks (see ADVERSE REACTIONS – Clinical Trial Adverse Drug Reactions), hypertension was reported at an incidence of 12.5% in the celecoxib group (400-800 mg daily dose) compared to 9.8% in the placebo group.

Abnormal Hematologic and Clinical Chemistry Findings

During the controlled clinical trials, there was an increased incidence of hyperchloremia in patients receiving celecoxib compared with patients on placebo. Other laboratory abnormalities that occurred more frequently in the patients receiving celecoxib included hypophosphatemia, and elevated urea. These laboratory abnormalities were also seen in patients who received comparator NSAIDs in these studies. The clinical significance of these abnormalities has not been established.

Post-Market Adverse Drug Reactions

Additional reports of serious adverse events temporally associated with CELEBREX during worldwide post-marketing experience are included below. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or clearly establish a causal relationship to CELEBREX exposure.

Blood and Lymphatic System Disorders:

Pancytopenia, agranulocytosis, aplastic anemia, leukopenia*

Serious bleeding events (some of them fatal) have been reported, predominantly in the elderly, in association with increases in prothrombin time in patients receiving CELEBREX concurrently with warfarin or similar agents (see DRUG INTERACTIONS)

Immune System Disorders:

Serious allergic reactions, anaphylactic shock

Psychiatric Disorders:

Confusion*, hallucination

Nervous System Disorders:

Aggravated epilepsy, aseptic meningitis, ageusia, anosmia

Ear and Labyrinth Disorders:

Decreased hearing

Eye Disorders:

Conjunctivitis

Cardiac Disorders:

Congestive heart failure, heart failure, myocardial infarction, arrhythmia**, syncope**, arterial thrombotic events

Vascular Disorders:

Vasculitis, cerebral hemorrhage, pulmonary embolism (some with fatal outcome), flushing**

Respiratory, Thoracic and Mediastinal Disorders:

Bronchospasm, pneumonitis

Gastrointestinal Disorders:

Gastrointestinal hemorrhage, acute pancreatitis, gastric ulcer**, duodenal ulcer**, esophageal ulcer**

Hepatobiliary Disorders:

Liver failure (with fatal outcome), fulminant hepatitis (with fatal outcome), liver necrosis, cholestasis, cholestatic hepatitis (with fatal outcome), hepatitis, jaundice

Skin and Subcutaneous Tissue Disorders:

Angioedema, isolated reports of skin exfoliation including: Stevens-Johnson syndrome, epidermal necrolysis, erythema multiforme, drug rash with eosinophilia and systemic symptoms (DRESS, or hypersensitivity syndrome), acute generalized exanthematous pustulosis (AGEP), bullous eruption, dermatitis bullous**

Reproductive System and Breast Disorders:

Menstrual disorder, female fertility decreased (see WARNINGS AND PRECAUTIONS Sexual Function/Reproduction), reduction of amniotic fluid volume, reduction of fetal urine production

Musculoskeletal and Connective Tissue Disorders:

Myositis

Renal and Urinary Disorders:

Acute renal failure, interstitial nephritis, nephrotic syndrome, acute glomerulonephritis, minimal change disease, hyponatremia

General Disorders and Administration Site Conditions:Chest pain

Serious Cardiovascular Adverse Events:

Meta-analyses and pharmacoepidemiological data point towards an increased risk of arteriothrombotic events associated with the use of CELEBREX, particularly at doses of >200 mg/day (see WARNINGS AND PRECAUTIONS – Serious Warnings and Precautions)

* Noted in both cumulative review of clinical trial data set and post-market adverse drug reactions
** Identified in cumulative review of clinical trial data set

Drug Interactions

Overview

General: Celecoxib metabolism is predominantly mediated via cytochrome P450 2C9 in the liver (commonly used drugs which are also substrates and/or inhibitors for cytochrome P450 2C9 include warfarin, fluoxetine, fluconazole, phenytoin, and tolbutamide). Co-administration of celecoxib with drugs that are known to inhibit 2C9 should be done with caution as it can lead to increases in plasma concentrations of celecoxib. Therefore a dose reduction of celecoxib may be necessary when celecoxib is co-administered with CYP2C9 inhibitors. Furthermore, patients who are known or suspected to be poor CYP2C9 metabolizers based on previous history/experience with other CYP2C9 substrates should be introduced celecoxib at half the lowest recommended dose, as they may have abnormally high plasma levels due to reduced metabolic clearance. The maximum recommended dose in CYP2C9 poor metabolizers is 100 mg daily.

Concomitant administration of celecoxib with inducers of CYP2C9 such as rifampicin, carbamazepine and barbiturates can lead to decreases in plasma concentrations of celecoxib. Therefore, a dose increase of celecoxib may be necessary when celecoxib is co-administered with CYP2C9 inducers.

A clinical pharmacokinetics study and in-vitro studies indicate that celecoxib, although not a substrate, is an inhibitor of CYP2D6. Therefore, there is a potential for an in vivo drug interaction with drugs that are metabolized by CYP2D6. A dose reduction during initiation of celecoxib treatment or a dose increase upon termination of celecoxib treatment may be necessary.

In vitro studies indicate that celecoxib is not an inhibitor of cytochrome P450 2C9, 2C19 or 3A4.

Drug-Drug Interactions

Acetylsalicylic Acid (ASA) or other NSAIDs: The use of CELEBREX (celecoxib) in addition to any other NSAID, including over-the-counter ones (such as ASA and ibuprofen), for analgesic and/or anti-inflammatory effects is NOT recommended because of the absence of any evidence demonstrating synergistic benefits and the potential for additive adverse reactions.

The exception is the use of low dose ASA for cardiovascular protection, when another NSAID is being used for its analgesic/anti-inflammatory effect, keeping in mind that combination NSAID therapy is associated with additive adverse reactions.

Some NSAIDs (e.g. ibuprofen) may interfere with the anti-platelet effects of low dose ASA, possibly by competing with ASA for access to the active site of cyclooxygenase-1.

As with all other NSAIDs, the concomitant administration of ASA with CELEBREX results in an increased rate of GI ulceration or other complications, compared to use of CELEBREX alone (see CLINICAL TRIALS - Special Studies). In the long-term outcomes study (at 4- and 2-fold the recommended doses for OA and RA, respectively), there was no statistically significant difference for the incidence of complicated ulcers between CELEBREX and comparator groups in patients taking ASA. Concomitant low dose ASA use increased the rate of complicated ulcers to four times that of patients not taking ASA. Resulting incidence rate for complicated ulcers in patients taking CELEBREX and ASA was 1.02%.

Antacids: Co-administration of CELEBREX with an aluminum- and magnesium-containing antacid resulted in a reduction in plasma celecoxib concentrations with a decrease of 37% in Cmax and 10% in AUC.

Pharmacokinetic parameters at steady state such as AUC and Cmax for both CELEBREX and omeprazole were comparable when administered alone or together in healthy volunteers (n=36). However increased Gastrointestinal (GI) and skin adverse events such as diarrhoea, abdominal pain, pruritis and rash were observed in combined arm of CELEBREX+omeprazole.

Anticoagulants: Anticoagulation / INR should be monitored in patients taking anticoagulants, particularly in the first few days after initiating or changing CELEBREX therapy, since these patients are at an increased risk of bleeding complications.

The effect of celecoxib on the anticoagulant effect of warfarin was studied in a group of healthy subjects receiving daily doses of 2-5 mg of warfarin (dose sufficient to prolong prothrombin times to 1.2 to 1.7 times their baseline values). In these subjects, celecoxib did not alter the anticoagulant effect of warfarin as determined by prothrombin time. However, in post-marketing experience, serious bleeding events (some of them fatal) have been reported, predominantly in the elderly, in association with increases in prothrombin time, in patients receiving CELEBREX concurrently with warfarin or similar agents (see ADVERSE REACTIONS - Post-Market Adverse Drug Reactions).

Anti-Hypertensives: NSAIDs may diminish the anti-hypertensive effects of Angiotensin Converting Enzyme (ACE) inhibitors, angiotensin receptor blockers, diuretics and beta blockers. Combinations of ACE inhibitors, angiotensin-II antagonists, or diuretics with NSAIDs might result in deterioration of renal function, including increased risk for acute renal failure and hyperkalemia, especially in patients who are elderly, volume-depleted (including those on diuretic therapy), or with compromised renal function. Blood pressure and renal function (including electrolytes) should be monitored more closely in this situation, as occasionally there can be a substantial increase in blood pressure.

Lisinopril: In a 28-day clinical study in patients with lisinopril-controlled Stage I and II hypertension, administration of celecoxib 200 mg BID resulted in no clinically significant increases, when compared to placebo treatment, in mean daily systolic or diastolic blood pressure as determined using 24-hour ambulatory blood pressure monitoring. Among patients co-administered with celecoxib 200 mg BID, 48% were considered unresponsive to lisinopril at the final clinic visit (defined as either cuff diastolic blood pressure >90 mmHg or cuff diastolic blood pressure increased >10% compared to baseline), compared to 27% of patients co-administered with placebo; this difference was statistically significant.

Anti-platelet Agents: There is an increased risk of bleeding, via inhibition of platelet function, where anti-platelet agents are combined with NSAIDs. CELEBREX does not generally affect platelet counts, prothrombin time (PT), or partial thromboplastin time (PTT), and does not appear to inhibit platelet aggregation at indicated dosages (see CLINICAL TRIALS - Special Studies – Platelets and WARNINGS AND PRECAUTIONS – Hematologic – Anti-platelet Effects).

Cyclosporin and Tacrolimus: Although this interaction has not been studied with celecoxib, co-administration of cyclosporin or tacrolimus and any NSAID may increase the nephrotoxic effect of cyclosporin or tacrolimus due to the NSAID's effect on renal prostaglandins. Renal function should be monitored when celecoxib and either of these drugs is used in combination.

Dextromethorphan and metoprolol: Concomitant administration of celecoxib 200 mg twice daily resulted in a 2.6-fold and a 1.5-fold increases in plasma concentrations of dextromethorphan and metoprolol (CYP2D6 substrates), respectively. These increases are due to celecoxib inhibition of metabolism via CYP2D6. Therefore, the dose of dextromethorphan or metoprolol may need to be reduced when treatment with celecoxib is initiated or increased when treatment with celecoxib is terminated.

Digoxin: No interaction data is available for the co-administration of celecoxib and digoxin. However an increase in serum digoxin level has been noted with some NSAIDS.

Diuretics: Clinical studies, as well as post-marketing observations, have shown that NSAIDs can reduce the effects of diuretics. This response has been attributed to inhibition of renal prostaglandin synthesis. Although prospective studies of CELEBREX with diuretics have not been conducted, no adverse reactions indicative of elevations in blood pressure were seen in clinical trials in which arthritis patients were taking CELEBREX concurrently with diuretics (n=485). No adverse reactions indicative of sodium retention or renal impairment were seen in clinical trials in patients taking CELEBREX concurrently with diuretics.

Fluconazole: Concomitant administration of fluconazole at 200 mg QD resulted in a two-fold increase in celecoxib plasma concentration. This increase is due to the inhibition of celecoxib metabolism via P450 2C9 by fluconazole (see ACTION AND CLINICAL PHARMACOLOGY - Pharmacokinetics - Metabolism). CELEBREX should be introduced at half the lowest recommended dose in patients receiving fluconazole, with a maximum recommended dose of 100 mg daily.

Glucocorticoids: Some studies have shown that the concomitant use of NSAIDs and oral glucocorticoids increase the risk of GI side effects such as ulceration and bleeding. This is especially the case in older (>65 years of age) individuals.

Ketoconazole: CELEBREX did not have a significant effect on the pharmacokinetics of ketoconazole.

Lithium: In a study conducted in healthy subjects, mean steady-state lithium plasma levels increased approximately 17% in subjects receiving lithium 450 mg BID with CELEBREX 200 mg BID as compared to subjects receiving lithium alone. Patients on lithium treatment should be closely monitored when CELEBREX is introduced or withdrawn.

Methotrexate: CELEBREX did not have a significant effect on the pharmacokinetics of methotrexate.

Oral contraceptives: In an interaction study, celecoxib had no clinically relevant effects on the pharmacokinetics of a prototype combination oral contraceptive (1 mg norethindrone/ 0.035 mg ethinyl estradiol).

Oral Hypoglycemics: The effect of celecoxib on the pharmacokinetics and/or pharmacodynamics of glyburide and tolbutamide has been studied and clinically important interactions have not been found.

Phenytoin: CELEBREX did not have a significant effect on the pharmacokinetics of phenytoin.

Other Drug Interactions: No drug interaction data are available for CELEBREX and the co-administration of the following products: acetaminophen, alcohol, aminoglycosides, bone marrow depressants, butamide, cholestyramine, colchicine, corticosteroids, gold compounds, indapamide, insulin, nephrotoxic agents, nonsteroidal anti-inflammatory agents, potassium supplements, probenecid, valproic acid, zidovudine.

Drug-Food Interactions

When CELEBREX capsules were taken with a high fat meal, peak plasma levels were delayed for about 1 to 2 hours with an increase in total absorption (AUC) of 10% to 20%. Under fasting conditions, at doses above 200 mg, there is less than a proportional increase in Cmax and AUC, which is thought to be due to the low solubility of the drug in aqueous media.

Drug-Herb Interactions

The interaction of CELEBREX with herbal medications or supplements has not been studied.

Drug-Laboratory test Interactions

Interactions with laboratory tests have not been established.

Dosage And Administration

Dosing Considerations

Cardiovascular disease or cardiovascular risk factors: Treatment with CELEBREX, particularly at doses higher than 200 mg per day, should not be used in patients with pre-existing cardiovascular disease (congestive heart failure (NYHA II-IV), ischemic heart disease), cerebrovascular disease, or patients with risk factors for cardiovascular disease (e.g. hypertension, hyperlipidemia, diabetes mellitus and smoking) (see WARNINGS AND PRECAUTIONS – Serious Warnings and Precautions).

Hepatic Impairment: CELEBREX capsules should be introduced at the lowest dose in patients with mild hepatic impairment (Child-Pugh 5-6). The daily recommended dose of CELEBREX capsules in patients with moderate hepatic impairment (Child-Pugh 7-9) should be reduced by 50% and should be given at the lowest dose of 100 mg once daily (see ACTION AND CLINICAL PHARMACOLOGY - Special Populations and Conditions). CELEBREX is contraindicated in patients with severe hepatic impairment (Child-Pugh >9) (see CONTRAINDICATIONS).

Renal Insufficiency: No dosage adjustment is necessary for patients with creatinine clearance >30 mL/min (see ACTION AND CLINICAL PHARMACOLOGY – Special Populations and Conditions). CELEBREX is contra-indicated in patients with severe renal impairment (estimated creatinine clearance <30 mL/min) (see CONTRAINDICATIONS).

Elderly (>65 years of age): In the elderly, frail and debilitated, the dosage should be reduced to the lowest level providing control of symptoms, and adjusted when necessary (see WARNINGS AND PRECAUTIONS – Special Populations – Geriatrics).

CYP2C9 Poor Metabolizers: Patients who are known, or suspected to be CYP2C9 poor metabolizers based on previous history/experience with other CYP2C9 substrates should be administered celecoxib with caution. Celecoxib should be introduced at half the lowest recommended dose in CYP2C9 poor metabolizers, with a maximum recommended dose of 100 mg daily (see DRUG INTERACTIONS and WARNINGS AND PRECAUTIONS – Special Populations).

Recommended Dose and Dosage Adjustment – 18 years of age and older
Use of CELEBREX should be limited to the lowest effective dose for the shortest possible duration of treatment (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS).

Osteoarthritis: The recommended daily dose of CELEBREX (celecoxib) is 200 mg administered as a single dose or as two divided doses (100 mg twice per day). Maximum dose = 200 mg a day.

Rheumatoid Arthritis: The recommended starting dose of CELEBREX is 100 mg twice per day, which may be increased to 200 mg twice per day if necessary. Maximum dose = 200 mg twice a day.

Ankylosing Spondylitis: The recommended daily dose of CELEBREX (celecoxib) is 200 mg administered as a single dose or as two divided doses (100 mg twice a day). Maximum dose = 200 mg a day.

Management of Acute Pain: The recommended dose of CELEBREX is 400 mg as a single dose on the first day followed by 200 mg once daily on subsequent days up to a maximum of 7 days. Patients may be instructed to take an additional dose of 200 mg on any given day, if needed. Maximum dose = 400 mg a day for up to 7 days.

Administration

CELEBREX can be taken with or without food.

Missed Dose

Patients who miss one or more doses of CELEBREX (celecoxib) should not increase the dose of CELEBREX to compensate for the missed dose or doses, but should continue therapy as soon as possible, then take the next dose at the scheduled time.

Overdosage

No overdoses of CELEBREX were reported during clinical trials. Doses up to 2400 mg/day for up to 10 days in 12 patients did not result in serious toxicity.

Symptoms following acute NSAID overdoses are usually limited to lethargy, drowsiness, nausea, vomiting, and epigastric pain, which are generally reversible with supportive care. Gastrointestinal bleeding can occur. Hypertension, acute renal failure, respiratory depression and coma may occur, but are rare. Anaphylactoid reactions have been reported with therapeutic ingestion of NSAIDs, and may occur following an overdose.

Patients should be managed by symptomatic and supportive care following an NSAID overdose. There are no specific antidotes. No information is available regarding the removal of celecoxib by hemodialysis, but based on its high degree of plasma protein binding (>97%) dialysis is unlikely to be useful in overdose. Emesis and/or activated charcoal (60 to 100 g in adults, 1 to 2 g/kg in children) and/or osmotic cathartic may be indicated in patients seen within 4 hours of ingestion with symptoms or following a large overdose. Forced diuresis, alkalinization of urine, hemodialysis, or hemoperfusion may not be useful due to high protein binding.

For management of a suspected drug overdose, contact your regional Poison Control Centre.

Action And Clinical Pharmacology

Mechanism of Action

CELEBREX (celecoxib) is a nonsteroidal anti-inflammatory drug that exhibits anti-inflammatory, analgesic, and anti-pyretic activities in animals. The mechanism of action of CELEBREX is believed to be related to inhibition of cyclooxygenase-2 (COX-2). COX-2 is expressed at high levels in inflamed tissues where it is induced by mediators of inflammation. COX-2 also plays physiological roles in a limited number of tissues, including those of the female reproductive tract, the kidney and possibly the vascular endothelium. COX-2 has the same catalytic activity as COX-1. COX-1 is expressed constitutively in most tissues including the gastrointestinal tract, kidney, lungs, brain, and platelets. The prostaglandins produced by COX-1 play key roles in the maintenance of physiological functions such as platelet aggregation and are among the factors that maintain the GI mucosal barrier. At therapeutic concentrations (see DOSAGE AND ADMINISTRATION) celecoxib inhibits COX-2 and does not inhibit COX-1.

Pharmacokinetics

The pharmacokinetics of celecoxib have been evaluated in approximately 1500 individuals. In addition to healthy, young and elderly volunteers (male and female), pharmacokinetic measurements have been done in patients and also in special populations including individuals with hepatic or renal impairment.

Absorption: Peak plasma levels of celecoxib occur approximately 3 hours after an oral dose. Both peak plasma levels (Cmax) and area under the curve (AUC) are roughly dose proportional across the clinical dose range of 100-200 mg studied. Under fasting conditions, at higher doses, there is a less than proportional increase in Cmax and AUC which is thought to be due to the low solubility of the drug in aqueous media. Because of the low solubility, absolute bioavailability studies have not been conducted. With multiple dosing, steady state conditions are reached on or before Day 5.

The pharmacokinetic parameters of celecoxib in a group of healthy subjects are shown in Table 3.

Table 3 Summary of Single Dose (200 mg) Disposition Kinetics of Celecoxib in Healthy Subjects1

Mean (%CV) Pharmacokinetic (PK) Parameter Values

(95% Confidence Interval)

Cmax,  ng/mL

Tmax,  hr

Effective t1/2,  hr

Vss/F,  L

CL/F,  L/hr

705 (38)

(484.2-925.0)

2.8 (37)

(1.95-3.71)

11.2 (31)

(8.3-14.0)

429 (34)

(307.2-551.5)

27.7 (28)

(21.3-34.1)

1Subjects under fasting conditions (n=36, 19-52 yrs.)

Food Effects: When CELEBREX capsules were taken with a high fat meal, peak plasma levels were delayed for about 1 to 2 hours with an increase in total absorption (AUC) of 10% to 20%. Co-administration of CELEBREX with an aluminum- and magnesium-containing antacid resulted in a reduction in plasma celecoxib concentrations with a decrease of 37% in Cmax and 10% in AUC. CELEBREX capsules can be administered without regard to the timing of meals.

Distribution: In healthy subjects, celecoxib is highly protein bound (~97%) within the clinical dose range. In vitro studies indicate that celecoxib binds primarily to albumin and, to a lesser extent, α1-acid glycoprotein. The apparent volume of distribution at steady state (Vss/F) is approximately 400 L, suggesting extensive distribution into the tissues. Celecoxib is not preferentially bound to red blood cells.

Metabolism: Celecoxib metabolism is primarily mediated via cytochrome P450 2C9. Three metabolites, a primary alcohol, the corresponding carboxylic acid and its glucuronide conjugate, have been identified in human plasma. These metabolites are inactive as COX-1 or COX-2 inhibitors. Cytochrome P450 2C9 activity is reduced in individuals with genetic polymorphisms that lead to reduced enzyme activity, such as those homozygous for the CYP2C9*3 polymorphism. Patients who are known or suspected to be P450 2C9 poor metabolizers based on a previous history should be administered celecoxib with caution as they may have abnormally high plasma levels due to reduced metabolic clearance. The maximum recommended dose in CYP2C9 poor metabolizers is 100 mg daily (see WARNINGS AND PRECAUTIONS - Special Populations - CYP2C9 Poor Metabolizers and DRUG INTERACTIONS).

In a pharmacokinetic study of celecoxib 200 mg administered once daily in healthy volunteers, genotyped as either CYP2C9*1/*1, CYP2C9*1/*3, or CYP2C9*3/*3, the median Cmax and AUC 0-24 of celecoxib on Day 7 were approximately 4-fold and 7-fold, respectively, in subjects genotyped as CYP2C9*3/*3 compared to other genotypes. In three separate single dose studies, involving a total of 5 subjects genotyped as CYP2C9*3/*3, single-dose AUC 0-24 increased by approximately 3-fold compared to normal metabolizers. It is estimated that the frequency of the homozygous *3/*3 genotype is 0.3 – 1.0% among different ethnic groups.

Excretion: Celecoxib is eliminated predominantly by hepatic metabolism with little (<3%) unchanged drug recovered in the urine and feces. Following a single oral dose of radiolabelled drug, approximately 57% of the dose was excreted in the feces and 27% was excreted into the urine. The primary metabolite in both urine and feces was the carboxylic acid metabolite (73% of dose) with low amounts of the glucuronide also appearing in the urine. It appears that the low solubility of the drug prolongs the absorption process making terminal half-life (t1/2) determinations more variable. The effective half-life is approximately 11 hours under fasted conditions. The apparent plasma clearance (CL/F) is about 500 mL/min.

Special Populations and Conditions

Geriatrics: At steady state, elderly subjects (over 65 years old) had a 40% higher Cmax and a 50% higher AUC compared to the young subjects. In elderly females, celecoxib Cmax and AUC are higher than those for elderly males, but these increases are predominantly due to lower body weight in elderly females. Dose adjustment in the elderly is not generally necessary. However, for elderly patients of less than 50 kg in body weight, initiate therapy at the lowest recommended dose, and as with all other NSAIDs, exercise caution in the use of higher doses.

Race: Meta-analysis of pharmacokinetic studies has suggested an approximately 40% higher AUC of celecoxib in black patients compared to Caucasians. The cause and clinical significance of this finding is unknown.

Hepatic Insufficiency: A pharmacokinetic study in subjects with mild (Child-Pugh 5-6) and moderate (Child-Pugh 7-9) hepatic impairment has shown that steady-state celecoxib AUC is increased about 40% and 180%, respectively, above that seen in healthy control subjects. Therefore, CELEBREX capsules should be introduced at a reduced dose in patients with moderate hepatic impairment. Patients with severe hepatic impairment have not been studied. The use of CELEBREX in patients with severe hepatic impairment is not recommended (see CONTRAINDICATIONS).

Renal Insufficiency: In a cross-study comparison, celecoxib AUC was approximately 40% lower in patients with chronic renal insufficiency (GFR 35-60 mL/min) than that seen in subjects with normal renal function. No significant relationship was found between GFR and celecoxib clearance. Patients with severe renal insufficiency have not been studied (see CONTRAINDICATIONS).

Storage And Stability

Store at room temperature (15-30° C).

Keep in a safe place out of reach of children and pets.

Dosage Forms, Composition And Packaging

CELEBREX (celecoxib) 100 mg capsules are white hard gelatin capsules with blue ink band on body marked in white with "100" and with “Pfizer 7767” marked in blue ink on cap. Supplied in bottles of 100 and 500.

CELEBREX 200 mg capsules are white hard gelatin capsules with gold ink band on body marked in white with "200" and with “Pfizer 7767” marked in gold ink on cap. Supplied in bottles of 100 and 500.

Composition: The inactive ingredients in CELEBREX 100 mg and 200 mg capsules include: croscarmellose sodium, lactose monohydrate, magnesium stearate, povidone, sodium lauryl sulfate. The capsules are made of gelatin and contain titanium dioxide (E171) and edible inks (ferric oxide (E172) for 200 mg capsules and indigotine (E132) for 100 mg capsules.

 

Control #: 202594
31 May 2017

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