When should COX-2 selective NSAIDs be used for osteoarthritis and rheumatoid arthritis?

Journal of Family Practice, March, 2006 by Vincent Lo, Susan Meadows

Many patients taking low-dose aspirin for cardioprotection also frequently require treatment of pain and inflammation with a NSMD. Even low-dose aspirin (75 mg/d) is known to be associated with increased GI toxicity (ulcers and hemorrhages). (11) A recent double-blind, randomized placebo-controlled trial found that 12 weeks of treatment with a combination of low-dose aspirin and a COX-2 selective NSMD (rofecoxib) had more than twice the incidence of endoscopically confirmed gastric and duodenal ulcers, compared with aspirin alone, and no difference with a nonselective NSAID. (12) This has raised the safety concern of concomitant use of a COX-2 selective NSAID with low-dose aspirin.

Recommendations from others

The American Pain Society recommends that for patients' with osteoarthritis, acetaminophen is the drug of choice for mild pain. (13) For moderate to severe pain and or inflammation, a COX-2 selective NSAID is the first choice, unless the patient is at significant risk for hypertension or renal disorder. For patients with active rheumatoid arthritis and moderate to severe pain with or without inflammation, a COX-2 selective NSAID should be used concomitantly with a disease-modifying antirheumatic drug (DMARD), unless contraindicated by existing uncontrolled hypertension and renal disease. It further recommends that for a person who is at risk for a cardiovascular event, an aspirin (75-160 mg/d), should be given along with a COX-2 selective NSAID.

The American College of Rheumatology recommends that a COX-2 selective NSAID should be considered for a person with osteoarthritis and pain not relieved by an adequate dose of acetaminophen (not to exceed 4 g/d). (14,15) The COX-2 selective NSAID is particularly advantageous for those who have higher risk factors for adverse GI events (TABLE 2). For a person with rheumatoid arthritis, in addition to DMARDs, NSAIDs (salicylates, nonselective NSAID, or COX-2 selective NSAID) should be used to reduce joint pain and swelling and improve joint function. Patients with additional risks for cardiovascular events should be cautioned about use of a COX-2 selective NSAID.

A recent AHRQ report on managing osteoarthritis underscores the importance of physician-patient partnership and patient's self management of osteoarthritis, and recommends acetaminophen (up to 4 g/day) as the drug of choice. (16) It further cautions the injudicious use of NSAIDs because of its greater GI toxicity when compared with acetaminophen, and its higher medical costs.

FAST TRACK

Using a nonselective NSAID and misoprostol or a PPI instead of a COX-2 inhibitor is a reasonable and proven strategy

FAST TRACK

Select patients for COX-2 inhibitors by considering risks:

* CV disease

* GI bleeding

* renal disease

* patient preference

* cost

REFERENCES

(1.) Bombardier C, Laine L, Reicin A, et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med 2000; 343:1520-1528.

(2.) Schnitzer TJ, Burmester GR, Mysler E, et al. Comparison of lumiracoxib with naproxen and ibuprofen in the Therapeutic Arthritis Research and Gastrointestinal Event Trial (TARGET), reduction in ulcer complications: randomised controlled trial. Lancet 2004; 364:665-674.