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Subcutaneous NSAIDs in palliative care - parecoxib

Palliative care
Red – For medicines normally initiated and used under specialist guidance

Introduction

The information below is intended for use in primary and secondary care to support the management of patients receiving parecoxib for cancer pain management in palliative care. Parecoxib is a non-steroidal anti-inflammatory drug (NSAID).

Subcutaneous parecoxib should only be started under specialist palliative care guidance and patients require ongoing specialist supervision.

Description

Parecoxib is an injectable pro-drug of valdecoxib, a selective COX-2 inhibitor.

Preparations

Note: Administration via the subcutaneous route is off-label use.

Injection

Parecoxib 40 mg, available as either:

  • vials containing 40mg powder only, or
  • vials containing 40mg powder and solvent for solution for injection

ALKALINE PH: Do not mix in continuous subcutaneous infusion (CSCI) with other drugs.

DILUENT: 0.9% sodium chloride

NOTE: May not be routinely available in primary care.

Indications

  • Parecoxib can be used for bone pain in cancer where standard therapies have been ineffective; this is unlicensed.

Contraindications

Refer to British National Formulary (BNF) or Summary of Product Characteristics (SPC) for a full list of contraindications.

Cautions

Skin reaction and allergy  

  • Serious skin reactions have been reported; patients are at highest risk when beginning treatment. Parecoxib should be discontinued at the first sign of skin reaction.
  • Parecoxib should be discontinued at the first sign of hypersensitivity reactions, for example, angioedema and anaphylaxis (frequency not known).

Cardiovascular risk 

  • Patients with significant cardiovascular risk factors (for example hypertension, hyperlipidaemia, diabetes mellitus, smoking).
  • Patients with increased risk of bleeding, particularly gastrointestinal.

Liver impairment 

  • In patients with moderate liver impairment, use with caution and reduce the starting dose to 20 mg, with a maximum dose of 40 mg daily.
  • Avoid use in those with severe liver impairment.

Renal impairment 

  • NSAIDs are not recommended in patients with renal impairment, but, if necessary, use with caution.
  • If eGFR <30, manufacturers recommend a lower starting dose of 20 mg.

Monitoring

  • Baseline and periodic monitoring of renal function, particularly in patients with pre-existing renal impairment or prolonged NSAID use.

Drug interactions

  • Increased risk of renal toxicity with other nephrotoxic drugs, an example being aminoglycosides.
  • Concomitant usage of parecoxib and anticoagulants increases risk of bleeding, therefore, caution must be used.
  • Increased risk of gastrointestinal side effects with corticosteroids, selective serotonin reuptake inhibitors (SSRIs), antiplatelet drugs, or alcohol.
  • Possible antagonistic effect with antihypertensives and diuretics because of sodium and fluid retention.
  • Concomitant usage of fluconazole may require a dose reduction of parecoxib.
  • Avoid concurrent usage with other non-steroidal anti-inflammatory drugs (NSAIDs).

Side effects

Common side effects:

  • hypertension, hypotension, peripheral oedema, dyspepsia, abdominal pain, flatulence, vomiting, hyperhidrosis, oliguria and nausea.

Rare but serious adverse effects:

  • severe skin reactions, for example, angioedema, erythema multiforme, Stevens-Johnson syndrome. Discontinue immediately if any of these occur.
  • gastrointestinal bleeding and perforation
  • cardiovascular thrombotic events.

Dose and administration

For the acute treatment of moderate to severe pain

40 mg can be administered by subcutaneous bolus injection. If necessary, increase to 40 mg twice daily, to a maximum of 80 mg in 24 hours.

In adults <50 kg or in the presence of moderate hepatic impairment, or severe renal impairment, halve the above doses.

For the treatment of intractable pain unresponsive to usual measures

Consider if a loading dose of 40 mg by subcutaneous bolus injection is needed, followed by CSCI.

CSCI:

  • 40–80 mg/24 hour in a 30 mL syringe
  • diluent: sodium chloride 0.9%
  • do not mix with other drugs.

Discontinuing parecoxib: seek specialist advice.

  • This may be needed if treatment is ineffective, the patient is experiencing side effects or is experiencing a site reaction.

Practice points

  • Consider prescribing a proton pump inhibitor for gastroprotection wherever possible, to reduce the risk of gastrointestinal complications.
  • Parecoxib's onset of analgesic effect has been reported to be around 30 minutes with a duration of action of 6–12 hours from a single dose.
  • Both COX-2 inhibitors and non-selective NSAIDs are associated with an increased risk of cardiovascular events with long-term use. Monitoring is advised in patients with high cardiovascular risk factors.

References

Electronic Medicine Compendium (EMC). SPC Dynastat 40mg Powder for Solution for Injection. 2012 [cited 1 April 2025]; Available from: https://www.medicines.org.uk/emc/product/1606/smpc#gref

British National Formulary (BNF). 89th Edition. England: Pharmaceutical Press. 2025.