Update from the American College of Rheumatology: Cox-2 Inhibitors and Why We Miss Them

Mark Borigini, M.D. Health Pro
  • When Cox-2 inhibitors first came on the market there was almost euphoria: Finally, those patients with chronic pain and in need of anti-inflammatory medication have a safer alternative to the "old" anti-inflammatory drugs such as Motrin and Naprosyn-drugs which carried with them an increased risk of hospitalization and even death due to bleeding ulcers.


    Indeed, the Cox-2 inhibitors were approved for, among other things, the treatment of rheumatoid arthritis, and many rheumatoid arthritis patients have used these drugs over the years.


    Unfortunately, researchers began to find that the Cox-2 inhibitors could in some cases be linked to heart attack and/or stroke. This resulted in the removal from the market of the Cox-2 inhibitors Vioxx and Bextra. It also resulted in the general decline in the use of Cox-2 inhibitors. At this time, in the United States, the only Cox-2 inhibitor on the market is Celebrex, and I have many patients who refuse to take this because they feel it might do them harm. And these patients instead choose to return to Motrin or Naprosyn.

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    Celebrex is FDA approved to treat the signs and symptoms of rheumatoid arthritis, the dosage being 100mg or 200mg twice daily.


    The problem is that these patients forget that the Cox-2 class of drugs was developed because harm was coming from Motrin, Naprosyn, Indocin and, of course, the granddaddy of anti-inflammatories: Aspirin. These drugs might be safer for the heart, but they can cause bleeding stomach ulcers. Patients need to protect the stomach if they choose to continue with these older drugs.


    Dr. Gurkirpal Singh of Stanford University Medical School presented research which showed that older patients who take these older anti-inflammatory drugs are doing so often with no stomach protection. He feels that we are therefore headed for a "public health disaster".


    And of course rheumatoid arthritis patients are at times older and more frail compared to the other type of patients who use pain and anti-inflammatory medications.


    Those patients who do have a risk for stomach ulcers should take a proton pump inhibitor (examples being Nexium, Protonix and Prevacid) which reduces the acid production in the stomach, or misoprostol (Cytotec), which coats and protects the lining of the stomach.


    The Cox-2 inhibitor Vioxx was removed from the market in September of 2004. The other Cox-2 inhibitor, Bextra, was withdrawn from the market in 2005.


    Interestingly, Dr. Singh found a 21% increase in gastrointestinal complications in 2005.


    It would appear that doctors-and perhaps patients also-have forgotten that potentially fatal stomach bleeds are still a threat to many patients, particularly as the population ages. Many of us have focused so much on the cardiovascular threat of anti-inflammatory treatment. We cannot afford to disregard the gastrointestinal threat of pain medications.


    Patients need to talk to their doctors about stomach protection, and doctors need to prescribe such protection for those patients who are at risk.


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    Let us not allow the headlines about heart attack and stroke due to the Cox-2 inhibitors erase the memories of the severe bleeding ulcers that can result from those "traditional" anti-inflammatory treatments.

Published On: December 20, 2007