FDA now looking at all Cox-2 Inhibitors

Pamela Egan Practical Practitioner

By: Pamela Egan, FNP-C CDE

FDA now looking at all Cox-2 Inhibitors

Lots of patients are asking about alternatives to Vioxx.

The jury is still out on whether the increased risk of heart attack and stroke seen with Vioxx is a class effect. There’s concern that all of the COX-2 inhibitors might increase cardiovascular risk by making blood clots more likely.

So far these risks haven’t been seen with Celebrex… possibly because it’s less selective for COX-2 than Vioxx. This means Celebrex might have less COX-2 benefits and less adverse effects.

But there is some evidence that Bextra might increase the risk of heart attacks in coronary bypass patients. And Bextra is more likely to cause serious skin reactions than Celebrex.

The FDA will now require a closer look at all COX-2’s. Patients will be re-assessed whether they need any COX-2 inhibitor. This depends on the risk of GI complications… and risk of heart disease.

For patients with a low GI risk, there’s no advantage in using a COX-2. It is recommended to use a traditional non-steroidal anti-inflammatory…naproxen, ibuprofen, etc.

For patients with a high GI risk it is recommended to use a traditional NSAID plus a proton pump inhibitor such as Nexium or Protonix…or a COX-2 if patients don’t have heart disease.

For patients on low-dose aspirin, there’s no benefit to using a COX-2 inhibitor…aspirin negates any GI benefit from using a COX-2. Try to avoid chronic ibuprofen. Chronic ibuprofen seems to interfere with aspirin’s anti-platelet effects. It is recommended to give a traditional NSAID with a PPI if needed to reduce GI risks for patients on aspirin.

Mobic (meloxicam) is getting more attention. Some call it a “COX-one-and-a-half” because it’s more selective than traditional NSAIDs…but not as much as a COX-2 inhibitor. But there’s no proof that Mobic reduces the risk of GI complications.

Keep in mind that all NSAIDS, including COX-2’s, can lead to edema, high blood pressure, or heart failure. All NSAID’s should be taken with food to avoid gastrointestinal adverse effects.

All patients should respect all the NSAID’s and use them only as needed. Long-term therapy should be monitored.

This article was originally published November 22, 2004 in The St. Tammany News.

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