South African Rheumatism and Arthritis Association
Motivation form for COXIBS

Doctor's name

 Patient name
Address Reference number
  Address
Phone number  
Fax number Phone number
email Medical aid Number

 

Requested Drug Celecoxib / Celebrex   Rofecoxib / Vioxx  

Reason
    

 

Diagnosis

Risk factor / Failed or intolerance to other NSAIDs
   

Factors

   Detail
Rheumatoid arthritis   Age    
Osteoarthritis   Sex    
Spondyloarthropathy   Corticosteroid therapy    
Ankylosing Spondylitis   Previous Ulcer    
Psoriatic Arthritis   Previous GI haemorrhage    
Reiter / Reactive arthritis   Warfarin    
Trauma        
Other   Previous intolerance    
    Other    
   

 Whereas all patients with chronic rheumatic conditions should receive COXIBs rather than NSAIDs due to the superior safety of these drugs, we recommend that these drugs should be mandatory in high risk patients requiring chronic NSAIDs as identified below.
1. Patients over 60 years of age.
2. Patients with previous proven peptic ulceration.
3. Patients on chronic corticosteroids.
4. Patients on Warfarin. It is suggested that where Healthcare Funders are unable to meet the financial obligation of chronic COXIB usage that the patient be given the option of contributing the extra cost above that of a standard NSAID.