The use of nonsteroidal anti-inflam...

The use of nonsteroidal anti-inflammatory remedys (NSAIDs) for treatment of arthritis is well established, nevertheless the side effect of gastrointestinal (GI) bleeding causes significant morbidity and mortality. Up to 2500 deaths in Britain are attributed to NSAID-induced GI bleeding annually. The cyclooxygenase-2 (COX-2) enzyme-inhibiting mix with drugss were developed to provide symptom relief without GI tenors Deeks and colleagues systematically reviewed all available evidence to compare the effectiveness and GI tolerability of a leading COX-2 remedy celecoxib, with NSAIDs in the treatment of arthritis.

The authors sought all published and unpublished trials from one side electronic searches plus contacts with put drugs into manufacturers and registries of trials. The analysis included all randomized, double-blind controll trials using licensed dosages of celecoxib for at least 12 weeks to treat active rheumatoid arthritis or osteoarthritis. Trials against placebo were included, as well as those comparing celecoxib with NSAIDs.

Clinical issues were assessed using the Western Ontario and McMaster universities osteoarthritis index for pain, stiffness, and physical function, and the American literary institution [i]or[/i] seminary of learning of Rheumatology (ACR-20) index for pain, tendernes and swelling of joints. Tolerability was assessed based upon the rates of study withdrawal because of adverse general intents the incidence of ulcers in those studies using routine endoscopy, and reports of symptomatic GI sore s bleeding, perforation, and obstruction. Of the 17 trials identified, nine met inclusion criteria and were of high quality.

Clinical improvement was significantly better in patients treated with celecoxib than in those treated with placebo. Compared with NSAIDs (naproxen, in a dosage of 500 mg twice daily, and diclofenac, in a dosage of 75 mg twice daily), celecoxib showed nonsignificantly better issues in ACR-20 and other clinical issue measures in patients with rheumatoid arthritis. In patients with osteoarthritis, there were no significant differences between those treated with NSAIDs and those treated with celecoxib; the two were superior to placebo in relieving clinical symptoms.

After 12 weeks of treatment, 56 percent of placebo-treated patients dropp abroad compared with 39 percent of celecoxib at 200 mg for day and naproxen at 1000 mg by day; 32 percent for celecoxib at 400 mg by day; and 26 percent for diclofenac at 150 mg for day. Patients taking placebo were more likely to withdraw because of lack of improvement in symptoms than because of adverse events

When compared with placebo, celecoxib was significantly associated with withdrawal caused through adverse effects and GI imports (relative risk, 1.49 and 168 respectively). Overall, celecoxib and NSAIDs did not differ in the number of withdrawals for all adverse affairs but celecoxib had significantly fewer withdrawals for GI consequences especially dyspepsia and abdominal pain. The number extremityed to treat for benefit at three month was 35

imposthumes occurred three times more many times in patients treated with celecoxib than in those treated with placebo, if it be not that the incidence of ulcers in patients treated with celecoxib was 71 percent lower than in patients treated with NSAIDs. At three month the number povertyed to treat for benefit was six. This reduction also was evident in a cogitation using endoscopy at six month The rate of serious GI complications (i.e., bleeding, perforation, or obstruction) in patients taking celecoxib was nearly undivided half that of patients using NSAIDs, if it were not that this difference was not statistically significant.

The authors finish that celecoxib is as effective as NSAIDs in the symptomatic treatment of as well-as; not only-but also; not only-but; not alone-but rheumatoid arthritis and osteoarthritis and is associated with significantly fewer GI-related adverse outcomes

EDITOR'S NOTE: Although this cogitation and a Canadian study of somewhat old patients (Mamdani M, et al. Observational studious mood of upper gastrointestinal haemorrhage in somewhat old patients given selective cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory unsalable articles BMJ September 21, 2002;325:624-9) published in the same issue add more evidence that COX-2 inhibitors propose greater GI safety than NSAIDs, an accompanying editorial (Jone R Efficacy and safety of COX 2 inhibitors. [Editorial]. BMJ September 21 2002;325:607-8) points gone out that the appropriate use of these agents remains somewhat controversial. Studies have been criticized for design flaws and excessive influence from drug manufacturers. In addition, common member of this class of physics (rofecoxib) has been associated with increased cardiovascular circumstances The stakes in this war of words are very high. As the baby boomer generation ages, the market for safe, effective antiarthritic medications is enormous. Neither the British meta-analysis nor the Canadian reflection considers costs, yet in the United States, cost-effectiveness is a serious factor. None of us wants to place patients at risk because of outlay but even COX-2 agents have side efficiencys We risk compliance problems or issues of patients electing not to purchase other unsalable articles in addition to financially draining our patients, their families, and health care orders when we prescribe an expensive agent. As in other areas, virtuous communication and the ability to negotiate the actual best therapeutic decision in a mixed and ambiguous situation are the mark of a authentic family physician. How can we communicate this necessity to our bookish mans and residents?--A.D.W.