Systematic review: coxibs, non‐steroidal anti‐inflammatory drugs or no cyclooxygenase inhibitors in gastroenterological high‐risk patients?

• Published in: Alimentary pharmacology & therapeutics Vol. 23; no. 1; pp. 27 - 33
• Main Authors: NIELSEN, O. H., AINSWORTH, M., CSILLAG, C., RASK‐MADSEN, J.
• Format: Journal Article
• Language: English
• Published: Oxford, UK Blackwell Science Ltd 01.01.2006
• Subjects: Anti-Inflammatory Agents, Non-Steroidal - adverse effects; Cardiovascular Diseases - chemically induced; Cardiovascular Diseases - prevention & control; Cyclooxygenase 2 Inhibitors - adverse effects; Gastrointestinal Diseases - drug therapy; Humans; Risk Factors
• ISSN: 0269-2813; 1365-2036
• DOI: 10.1111/j.1365-2036.2006.02745.x

Summary Selective cyclooxygenase‐2 inhibitors have been marketed as alternatives of conventional, non‐steroidal anti‐inflammatory drugs with the purpose of reducing/eliminating the risk of ulcer complications. Unexpectedly, randomized‐controlled trials revealed that long‐term use of coxibs, such as rofecoxib, significantly increased the risk of myocardial infarction and stroke, while the use of valdecoxib was associated with potentially life‐threatening skin reactions. Subsequently, rofecoxib and valdecoxib were withdrawn from the market. Although more strict precautions for other coxibs, such as celecoxib, etoricoxib, lumiracoxib and parecoxib, may be accepted/recommended by regulatory agencies, a critical review of published data suggests that their use may not be justified – even in high‐risk patients – taking benefits, costs and risks into consideration. Clinicians should, therefore, never prescribe coxibs to patients with cardiovascular risk factors, and should only reluctantly prescribe coxibs to patients with a history of ulcer disease or dyspepsia to overcome persistent pain due to, e.g. rheumatoid arthritis or osteoarthritis. Instead, they should consider using conventional non‐steroidal anti‐inflammatory drugs in combination with a proton pump inhibitor or a prostaglandin analogue, especially for patients with increased cardiovascular risks, i.e. established ischaemic heart disease, cerebrovascular disease and/or peripheral arterial disease, or alternatively acetaminophen. An evidence‐based algorithm for treatment of a chronic arthritis patient with one or more gastrointestinal risk factors is presented.