Approaches to nonsteroidal anti-inflammatory drug use in the high-risk patient

Review article: should NSAID/low-dose aspirin takers be tested routinely for H. pylori infection and treated if positive? Implications for primary risk of ulcer and ulcer relapse after initial healing

Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) can each result in gastric or duodenal ulcer(s) and ulcer complications. Together, H. pylori infection and NSAIDs account for approximately 90% of peptic ulcer disease. In 2003, the results of studies suggest, and guidelines recommend, the careful selection of anti-inflammatory drugs - NSAIDs or selective COX-2 inhibitors (coxibs) based upon patients gastrointestinal history and use of aspirin therapy. Testing for, and cure of, H. pylori infection is recommended in patients prior to the initiation of NSAID therapy and in those who are currently receiving NSAIDs and have a history of dyspepsia, peptic ulcer or ulcer complications. For patients who present with peptic ulcer bleeding but require NSAIDs long-term, H. pylori eradication therapy should be considered, followed by continuous proton pump inhibitor prophylaxis to prevent re-bleeding, regardless of which kind of NSAID (nonselective NSAID /coxib) is being prescribed. Routine testing for, and eradication of, H. pylori infection has not been recommended for current takers of NSAIDs with no or low risk of complications. The management of patients taking low-dose aspirin is complex, but eradication of H. pylori infection alone in those with a past history of bleeding does not guarantee complete protection and therefore a proton pump inhibitor should also be given. The success of eradication therapy should always be confirmed, because of the risk of ulcer recurrence and bleeding in H. pylori-infected patients who require anti-inflammatory treatments.

Review article: appropriate use of proton pump inhibitors with traditional nonsteroidal anti-inflammatory drugs and COX-2 selective inhibitors

Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used classes of medications in the USA, annually accounting for over 100 million prescriptions. Gastrointestinal complications associated with NSAIDs are common, and result in a substantial amount of morbidity and mortality, despite the advent of the cyclooxygenase-2 selective inhibitors or 'coxibs'. Emerging clinical and economic data suggest that, depending on the baseline risk to patients, the use of a traditional NSAID alone or in combination with a proton pump inhibitor are effective and well tolerated alternatives to coxibs. The optimal therapeutic strategy for NSAID selection and use of co-therapy should be guided by a consideration of each patient's risk of having an adverse event arising from the NSAID. Patients at the highest risk for gastrointestinal complications with traditional NSAIDs are those with a history of an ulcer or ulcer complication, those of advanced age (greater than 65 years), and those receiving concurrent aspirin, anticoagulants or corticosteroid therapy. Proton pump inhibitor co-therapy is highly effective in reducing NSAID-related dyspeptic symptoms, healing the injured mucosa even in those who continue to ingest NSAIDs, and preventing gastrointestinal complications. In addition to their selective use in patients who experience NSAID-related dyspepsia and other symptoms, proton pump inhibitor co-therapy should be considered in those at high risk (with coxib or traditional NSAID therapy) and is necessary in high-risk patients receiving aspirin, with or without NSAID therapy.

Guidelines for the appropriate use of non-steroidal anti-inflammatory drugs, cyclo-oxygenase-2-specific inhibitors and proton pump inhibitors in patients requiring chronic anti-inflammatory therapy

AIM

To rationalize decision making around the use of different non-steroidal anti-inflammatory drug (NSAID) treatment strategies in patients with varying degrees of gastrointestinal and cardiovascular risk.

METHODS

The panel comprised nine physicians (three rheumatologists, two internists, two gastroenterologists and two cardiologists) from geographically diverse areas practising in community-based settings (n = 4) and academic institutions (n = 5). A literature review was performed by the authors on the risks, benefits and costs of NSAIDs, cyclo-oxygenase-2-specific inhibitors and proton pump inhibitor co-therapy. The RAND/UCLA Appropriateness Method was used to rate 304 clinical scenarios as 'appropriate', 'uncertain' or 'inappropriate'.

RESULTS

In patients with no previous gastrointestinal event and not concurrently on aspirin (low risk), the panel rated the use of an NSAID alone as 'appropriate' for those aged < 65 years, and the use of an NSAID +proton pump inhibitor or cyclo-oxygenase-2-specific inhibitor + proton pump inhibitor as 'inappropriate'. For patients aged > 65 years and at low risk, an NSAID or cyclo-oxygenase-2-specific inhibitor alone was rated as 'uncertain'. For patients with a previous gastrointestinal event or who concurrently received aspirin, an NSAID alone was rated as 'inappropriate', and either a cyclo-oxygenase-2-specific inhibitor or an NSAID +proton pump inhibitor was rated as 'appropriate'. Finally, for patients with a previous gastrointestinal event and on aspirin, an NSAID or cyclo-oxygenase-2-specific inhibitor in conjunction with a proton pump inhibitor was rated as 'appropriate'.

CONCLUSIONS

Clinicians and managed care entities need to balance the risks, benefits and costs of NSAIDs, cyclo-oxygenase-2-specific inhibitors and the prophylactic use of proton pump inhibitors. The guidelines given here can assist this process.

Assessment of the safety of selective cyclo-oxygenase-2 inhibitors: where are we in 2003?

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used drugs worldwide despite their well-documented adverse gastrointestinal (GI) effects. The risk of developing a severe GI event varies from patient to patient and NSAID to NSAID. Selective cyclo-oxygenase-2 inhibitors (coxibs) have been designed to have similar efficacy but less GI toxicity than traditional NSAIDs, and have been shown to have an improved GI tolerability and less adverse events across a range of different GI safety assessments. In clinical trials, particularly VIGOR and CLASS, rofecoxib and celecoxib, respectively, significantly reduce the risk of ulcers and ulcer complications than nonselective NSAID comparators with ulcer rates comparable to placebo. The real benefit of a coxib comes from the sparing of the thromboxane and hence preservation of normal platelet function. Thus, there is less risk of bleeding with selective inhibition of COX-2, which is the most common and serious complication of non-selective NSAIDs. Moreover, bleeding can occur anywhere in the GI tract. Although some concern has been raised about the cardiovascular safety of coxibs, when used in recommended doses, there is no convincing evidence that patients treated with a coxib have an increased risk of cardiovascular thrombotic events. Different approaches have been advocated to minimize NSAID-related GI toxicity. Choice of less harmful NSAIDs such as coxib has been one of the strategies promoted in guidelines. The introduction of coxibs with a higher benefit-risk ratio has dramatically changed the therapeutic scenario for anti-inflammatory treatment in the clinical practice.

Nonvariceal upper gastrointestinal bleeding

Nonvariceal UGI bleeding is one of the most common emergencies that gastroenterologists encounter, and continues to be a significant cause of morbidity and mortality. The keys to management are rapid resuscitation and stabilization; appropriate triage based on pre-endoscopic risk factors; early endoscopy to achieve prompt diagnosis and implement hemostatic therapy to high-risk lesions; and aggressive antisecretory therapy (in the case of peptic ulcer bleeding) to reduce the risk of continued or recurrent bleeding.

COX-inhibiting nitric oxide donators (CINODs) -- a new paradigm in the treatment of pain and inflammation

The clinical utility of non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief is tempered by their propensity to cause gastrointestinal toxicity. Cyclooxygenase (COX)-inhibiting nitric oxide donators (CINODs) are a new class of drugs designed to provide analgesic efficacy through COX inhibition and gastrointestinal safety through the protective effects of controlled nitric oxide donation. Pre-clinical studies assessing the pharmacology, efficacy and gastrointestinal safety of AZD3582 [4-(nitrooxy)butyl-(2S)-2-(6-methoxy-2-naphthyl)propanoate] support this concept. Based on these studies, AZD3582 was the first CINOD to enter clinical development for the treatment of acute and chronic pain. The potential clinical utility of this new class is illustrated by a study of AZD3582 in healthy volunteers in which it caused significantly less acute gastrointestinal toxicity than an equimolar dose of naproxen. The results of the animal studies and the initial clinical study warrant long-term tolerability studies of AZD3582 along with evaluation of its anti-inflammatory and analgesic effects in humans.

The role of cyclooxygenase selective inhibitors in the gastrointestinal tract

This article reviews the gastrointestinal manifestations of traditional nonsteroidal anti-inflammatory drugs (NSAIDs) and the improved gastrointestinal safety profile of cyclooxygenase selective (COX)-2 inhibitors. By inhibiting the COX enzyme, NSAIDs provide effective analgesia and suppress inflammation in a variety of conditions. Most NSAIDs (nonselective or traditional) not only inhibit prostaglandins at sites of inflammation but also inhibit prostaglandins that have important normal functions in other parts of the body. This may be harmful when normal gastrointestinal mucosal function is impaired and mucosal damage occurs. Although such damage is often trivial and usually not symptomatic, gastrointestinal ulceration may produce pain and, more ominously, lead to bleeding, perforation, or obstruction. A new approach to the gastrointestinal complications of NSAIDs became feasible with the discovery of two isoforms of COX, COX-1 and COX-2, with COX-1 expressed mainly in the gastrointestinal tract. The development of NSAIDs that preferentially inhibit COX-2 offers the promise of relieving pain and inflammation without the side effects attendant to COX-1 blockade. In prospective studies evaluating gastrointestinal ulceration with COX-2-specific NSAIDs, rates of endoscopic ulceration have been equivalent to those with placebo and much lower than those with nonselective NSAIDs. In the recently released studies of gastrointestinal outcomes (perforated, painful, or bleeding ulcers), incidence of clinically relevant ulceration with COX-2 NSAIDs is much lower than that of traditional NSAIDs.

The CINOD, AZD3582, exhibits an improved gastrointestinal safety profile compared with naproxen in healthy volunteers

COX-inhibiting nitric oxide donators (CINODs) are a new class of drugs in development for the treatment of acute and chronic pain. They comprise a COX-inhibiting moiety linked to a nitric-oxide-donating component and are designed to provide an innovative mechanism of action of balanced COX inhibition and controlled nitric oxide donation. Through these pathways, CINODs should provide analgesic and anti-inflammatory efficacy, while offering gastrointestinal safety through the tissue-protective effects of nitric oxide donation. AZD3582 [4-(nitrooxy)butyl-(2S)-2-(6-methoxy-2-naphthyl)propanoate] is the first agent in the CINOD class to enter extensive clinical development. Pre-clinical studies demonstrate that AZD3582 has a superior gastrointestinal safety profile to naproxen, while demonstrating analgesic and anti-inflammatory efficacy. In healthy human volunteers, AZD3582 caused little gastrointestinal damage compared with equimolar doses of naproxen. Studies to evaluate the longer-term gastrointestinal safety of AZD3582, alongside its efficacy in alleviating chronic and acute pain, are ongoing.

Gastroprotection by coxibs: what do the Celecoxib Long-Term Arthritis Safety Study and the Vioxx Gastrointestinal Outcomes Research Trial tell us?

Current evidence suggests that PPIs might be effective in maintaining patients in remission during continued NSAID use and that the combination of omeprazole plus diclofenac is as effective as treatment with celecoxib in preventing recurrent bleeding. Larger outcome studies comparing the combination of a PPI with other nonselective NSAIDs and a selective COX-2 inhibitor (and the combination of a selective COX-2 inhibitor with a PPI or misoprostol) are required to determine whether or not any regimen will further decrease or eliminate the risk of ulcer complications in high-risk individuals.

Peroxisome proliferator-activated receptor γ activation counters the detrimental effect of Helicobacter pylori lipopolysaccharide on gastric mucin synthesis

Peroxisome proliferator-activated receptor-gamma (PPARgamma), a member of the subfamily of ligand-dependent nuclear transcription factors, plays a key role in the regulation of the expression of genes associated with inflammation. In this study, using gastric mucosal cells in culture, we assess the role of PPARgamma in the disturbances in gastric mucin synthesis and apoptotic processes evoked by Helicobacter pylori lipopolysaccharide (LPS). Exposure of gastric mucosal cells to the LPS led to a concentration-dependent decrease (up to 59.5%) in mucin synthesis, and this effect of the LPS was accompanied by a 6.5-fold increase in apoptosis, induction of COX-2 and NOS-2 protein expression, and the enhancement in PGE(2) generation (18.6-fold) and NOS-2 activity (24.1-fold). However, the expression of COX-1 protein was not affected. Activation of PPARgamma with a specific synthetic agonist, ciglitazone, countered (up to 90.2%) the LPS-induced reduction in mucin synthesis in a concentration-dependent manner, and this effect of the agent was reflected in a marked decrease in COX-2 and NOS-2 protein expression, reduction (up to 72.4%) in apoptosis and a decline (up to 84.1%) in PGE(2) generation and NOS-2 activity (up to 90%). A pronounced prevention (88.2%) in the LPS-induced PGE(2) release and the diminished COX-2 protein expression was also attained with the COX-2-selective inhibitor NS-398, but the effect was not associated with the impedance of the LPS inhibitory effect on mucin synthesis. Our findings thus demonstrate that the detrimental influence of H. pylori LPS on gastric mucin synthesis is closely linked to the increase in proapoptotic processes triggered by NOS-2 upregulation, and that PPARgamma activation obviates this detrimental effect. Hence, pharmacological manipulation of PPARgamma activation may provide therapeutic benefits in countering the disruptive effects of H. pylori on gastric mucosal mucus coat continuity.

Gastro-protective treatment in patients using NSAIDs. Development of appropriateness criteria by a multidisciplinary expert panel

OBJECTIVE

To refine the appropriate indications for gastro-protective treatment in patients using non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

Using the RAND Appropriateness Method, a multidisciplinary expert panel was asked to rate the appropriateness of gastro-protection for 4608 different cases. Logistic regression was used to construct a decision framework to identify patients for whom gastro-protective medication should be considered.

RESULTS

Complete consensus existed on the appropriate use of gastro-protection in patients with a history of (un)complicated peptic ulcer. For other patients. agreement was found for 39% over 1536 cases. Logistic regression demonstrated strong consistency of the panel ratings (Hosmer Lemeshow coefficient 0.92), allowing the development of a comprehensive decision support model.

CONCLUSIONS

Using the RAND Appropriateness Method, we were able to develop a clear and internally consistent decision framework for the appropriate use of gastro-protection in patients taking NSAIDs. The validity of this model should be tested in further studies and practice.

Gastrointestinal health care resource utilization with chronic use of COX-2-specific inhibitors versus traditional NSAIDs

BACKGROUND & AIMS

Cyclooxygenase 2 (COX-2)-specific inhibitors (coxibs) decrease gastrointestinal (GI) events in controlled trials, but results in clinical practice are unknown. We assessed GI-related resource use and costs in patients switching from chronic nonsteroidal anti-inflammatory drug (NSAID) therapy to chronic coxib therapy and in patients starting chronic NSAID therapy vs. chronic coxib therapy in a U.S. administrative claims database of >8 million lives.

METHODS

"Switchers" (n = 2246) were assessed in the 12-month periods before and after switching from chronic NSAID therapy to coxib therapy. "New NSAID" (n = 25,989) and "new coxib" (n = 2125) groups were assessed for the 12-month periods before and after the initial prescription. Proportions of patients with GI resource use (odds ratio [OR] adjusted for relevant covariates) and costs were compared.

RESULTS

The adjusted OR for any GI resource use (coxib vs. NSAID period) among switchers was 0.86 (0.74-0.99). The decrease was due to less GI cotherapy (OR = 0.82 [0.69-0.97]). Costs were not significantly lower after switching to coxibs (mean difference, -$19; 95% CI: -$139, $55), although after adding NSAID/coxib costs, the total cost in the coxib period was significantly higher (mean increase, $377; $271, $488). Adjusted OR for GI resource use for new-coxib vs. new-NSAID was 1.04 (0.92-1.16), but GI costs were significantly lower in new-NSAID patients.

CONCLUSIONS

Patients switching from chronic NSAID therapy to chronic coxib therapy had a slight decrease in the proportion using GI-related resources but not in GI costs. When NSAID/coxib drug costs were included, costs were significantly less with NSAIDs than with coxibs. The potential GI-related cost savings suggested in coxib clinical trials may not be fully realized in "real-world" settings.

The gastrointestinal safety of the COX-2 selective inhibitor etoricoxib assessed by both endoscopy and analysis of upper gastrointestinal events

OBJECTIVES

Etoricoxib is a selective cyclooxygenase inhibitor that in clinical studies has improved the signs and symptoms of osteoarthritis and rheumatoid arthritis and reduced the potential for GI injury. The incidence of endoscopically detected ulcers and of clinically important upper GI events (perforations, ulcers, and bleeding episodes) was compared in patients taking etoricoxib or nonselective nonsteroidal anti-inflammatory drugs (NSAIDs).

METHODS

Upper GI endoscopy was performed at intervals over 12 wk in 680 patients taking etoricoxib 120 mg once daily, ibuprofen 800 mg three times daily, or placebo in a randomized, parallel-group, double-blind study. Survival analysis was used to analyze time-to-event data for the incidence of gastric or duodenal ulcers (> or =3 mm and > or =5 mm), and the log rank test was used to compare the cumulative incidence between treatment groups. A combined analysis of upper GI events in all 10 Phase II/III clinical trials of etoricoxib (60, 90, or 120 mg) versus nonselective NSAIDs (naproxen, ibuprofen, or diclofenac) for osteoarthritis, rheumatoid arthritis, and chronic low back pain was conducted. Investigators reported potential events for adjudication by an external, blinded committee, using prespecified criteria to confirm events. All events that occurred during active treatment periods (maximum 792 days) or within 14 days of stopping treatment were included in the analysis. Time to first event was evaluated using survival analysis; the Kaplan-Meier method was used to determine the cumulative incidence, and relative risk was estimated with the Cox proportional hazards model.

RESULTS

In the endoscopy study, the cumulative incidence of ulcers >/=3 mm at 12 wk in the ibuprofen group (17%) was significantly higher than in the etoricoxib group (8.1%, p < 0.001); similar results were seen for ulcers >/=5 mm. In the placebo group, the rate of ulcers >/=3 mm was 1.86%. Of 3142 patients treated with once-daily etoricoxib and 1828 patients treated with a nonselective NSAID (ibuprofen, naproxen, or diclofenac), 82 patients with investigator-reported upper GI events (71 confirmed) were eligible for the combined analysis. For etoricoxib versus NSAIDs, the rate per 100 patient-yr for confirmed events was 1.16 versus 3.05 (relative risk = 0.44, 95% CI = 0.27-0.72, p < 0.001), whereas that for investigator-reported events was 1.35 versus 3.42 (relative risk = 0.47, 95% CI = 0.30-0.74, p = 0.001). Results were driven primarily by studies with naproxen as the comparator.

CONCLUSIONS

The incidence of endoscopically detected ulcers was significantly lower with etoricoxib 120 mg than with ibuprofen 2400 mg. Treatment with etoricoxib reduced the incidence of investigator-reported and confirmed adverse upper GI events by approximately 50% compared with treatment with nonselective NSAIDs.

The specific expression of hypoxia inducible factor-1alpha in human gastric mucosa induced by nonsteroidal anti-inflammatory drugs

BACKGROUND

Hypoxia is a cause of gastric mucosal damage induced by nonsteroidal anti-inflammatory drugs (NSAIDs). The expression of hypoxia inducible factor-1alpha (HIF-1alpha) reflects the status of tissue ischaemia.

AIM

To investigate the effect of NSAID administration on the expression of HIF-1alpha in human gastric mucosa.

METHODS

We employed 71 patients including 14 with NSAID administration. The HIF-1alpha expression was estimated by immunohistochemistry using monoclonal antibody (H1alpha67) and raised antiserum (HI-3). Vascular endothelial growth factor expression was also examined by immunohistochemistry. HI-3 recognized hypoxia-induced protein in HeLa cells.

RESULTS

In human gastric mucosa, HIF-1alpha was mainly expressed in the nuclei of the surface epithelial cells and in the neck zone both by use of HI-3 and of H1alpha67. The expression of vascular endothelial growth factor correlated well with that of HIF-1alpha. The level of HIF-1alpha in the surface epithelium was significantly higher in patients with administration of NSAIDs than those without NSAID use (P < 0.001) both in the gastric corpus and antrum. Helicobacter pylori infection did not affected the levels of HIF-1alpha. Long-term administration of rebamipide reduced the level of HIF-1alpha.

CONCLUSION

HIF-1alpha expression is a new biological marker of ischaemia especially in NSAID-related gastric lesions.

[An overview of acetic acid ulcer models and their utility for drug screening]

Since Takagi et al. reported an experimental chronic gastric ulcer model [acetic acid ulcers induced by submucosal injection of acetic acid (Type 1)], we further modified the methodology and subsequently devised three more models. The second model involves inducing ulcers by serosal application of an acetic acid solution (Type 2) and the third model achieves ulcer induction by intragastric application of an acetic acid solution (Type 3). The forth model was modification of the third model by giving the acetic acid solution and the same volume of air to make one ulcer in the stomach (Type 4). In general, animals accepted the procedures without problems and no undesirable effects were noticed. More importantly, this experimental animal model allows production of ulcers that highly resemble human ulcers in terms of both pathology and healing. Indeed, relapse is even endoscopically observed for 360 days after ulceration. The ulcers produced not only respond well to various anti-ulcer medications, such as antisecretory and mucosal protective drugs and growth factors, but also demonstrate appropriate responses to ulcerogenic agents such as NSAIDs. In addition, we have recently demonstrated that H. pylori infection resulted in delayed ulcer healing and recurrence of healed acetic acid ulcers induced in Mongolian gerbils. The present article gives a brief summary of the ulcer history before establishment of acetic acid ulcers and characteristic features of acetic acid ulcer, including both their merits and shortcomings.

Outcome trials of COX-2 selective inhibitors: global safety evaluation does not promise benefits

BACKGROUND

Gastrointestinal toxicity is the most frequent adverse effect associated with nonsteroidal anti-inflammatory drug use. The most clinically relevant side effects of this toxicity are ulcer complications, including perforation, obstruction, or bleeding. Selective cyclooxygenase (COX-2) inhibitors (coxibs) have been proposed as a safer alternative to traditional, nonsteroidal anti-inflammatory drugs and they are currently widely used in clinical practice. The aim of this review was to analyze the available evidence and then critically evaluate the outcome trials supporting the use of coxibs in terms of their clinical gastrointestinal benefits and global safety.

METHODS

All published clinical trials on selective COX-2 inhibitors were identified by searching Medline, the World Wide Web (WWW), and abstracts in Congress proceedings. From these, we selected randomized trials that clinically evaluated relevant safety outcome measures. Papers only describing endoscopic evaluation were excluded.

RESULTS

Our search yielded three outcome trials and two pooled safety analyses. The outcome studies supporting the gastrointestinal and global safety of coxibs were found to be biased in their design, analysis, and dissemination, and interpretation of a clinical benefit. Cost considerations would make the use of coxibs acceptable only in patients at high gastrointestinal risk.

CONCLUSIONS

The association of the reduced gastroerosive potential of coxibs with improved meaningful outcomes is debatable. Bias in the design of the trials, selection of outcome measures, post-hoc changes in analysis and the variables used, as well as flaws in the publication and reporting of trial results cast serious doubts on the gastrointestinal and global safety profile of coxibs. In addition, their high cost and the lack of clear identification of patients that would benefit most from treatment means the effectiveness of these drugs is uncertain at the moment.

Safety profile of rofecoxib as used in general practice in England: results of a prescription-event monitoring study

AIMS

A postmarketing Prescription-Event Monitoring study was undertaken to monitor the safety of rofecoxib, a cyclo-oxygenase (COX)-2 selective inhibitor prescribed in primary care in England.

METHODS

Questionnaires requesting clinical event data were sent to prescribing physicians between February and November 2000, and the data analysed for all events.

RESULTS

There were 15,268 patients identified, mean age 62 years, 67% female. The commonest specified indication was osteoarthritis (24%). Dyspepsia and nausea were the most frequently reported adverse events. A history of dyspeptic or upper gastrointestinal (GI) conditions, recent use of other nonsteroidal anti-inflammatory drugs (NSAIDs), use of selected concomitant gastroirritant drugs (NSAIDs, aspirin, anticoagulants, antiplatelet drugs), or gastroprotective drugs (misoprostol, antacids, proton-pump inhibitors, histamine-2 antagonists), and age (>/= 65 years) modified the risk of having minor GI events. During treatment or within 1 month of stopping, 110 serious GI events were reported (including 76 upper GI bleeds/peptic ulcers, one perforated colon), 101 thromboembolic events, three reports of acute renal failure, one each of Stevens-Johnson syndrome, severe anaphylaxis and angio-oedema.

CONCLUSIONS

Doctors should continue to prescribe NSAIDs including COX-2 selective inhibitors with caution.

Gastrointestinal effects of NSAIDs and coxibs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used drugs in the world, but their use is limited because of their propensity to cause gastrointestinal (GI) injury. All patients are at risk of GI injury but certain risk factors increase the likelihood of adverse GI effects. The most important include a history of ulcer or GI complications, increasing age, concomitant anticoagulation, concomitant corticosteroid use, and high-dose NSAIDs or multiple NSAIDs (including an NSAID plus low-dose aspirin). Concurrent illness (e.g., severe rheumatoid arthritis, heart disease) has also been reported to increase the risk of GI events. NSAID-associated GI side effects markedly increase health care costs, with up to 31% of cost of managing arthritis patients accounted for through the management of GI side effects. The COX-2 specific inhibitors (coxibs) were developed with the aim of maintaining anti-inflammatory efficacy but improving gastrointestinal safety in comparison to non-selective NSAIDs. The use of COX-2 specific inhibitors significantly decreases the rate of endoscopic ulcers as compared to traditional NSAIDs. Prospective GI outcomes studies also indicate that these agents decrease clinical GI events as compared to non-selective NSAIDs. The number of patients needed to treat to avert one clinical event in one year is approximately 40-100. The cost-effectiveness of coxibs increases (the cost per GI event averted decreases) in patients with high-risk clinical features because they have higher rates of GI hospitalizations and greater use of expensive prophylactic co-therapy.

Management pattern for patients with osteoarthritis treated with traditional non-steroidal anti-inflammatory drugs in Spain prior to introduction of Coxibs

OBJECTIVE

To investigate the use of traditional non-steroidal anti-inflammatory drugs (tNSAIDs) in the management of osteoarthritis (OA) in primary care in Spain and to quantify patient and physician satisfaction with tNSAID therapy.

METHODS

A 6-month retrospective, observational study conducted in 29 Spanish primary-care centres shortly before the first introduction of selective COX-2 inhibitors (Coxibs).

RESULTS

A total of 897 patients with a mean age 66 +/- 9 years and radiologically documented OA were included: most (76%) were women. Three-quarters of the patients had primary generalised OA, with the knees (> 60% of cases) and lumbar spine (> 50% of cases) being the sites most commonly affected. Pain was an almost universal feature of the clinical presentation. More than 96% of patients had been prescribed tNSAIDs during the observation period, predominantly for pain relief. The most commonly prescribed agents were diclofenac, aceclofenac and piroxicam. Twenty-six per cent of discontinuations of tNSAIDs during the observation period were due to limited effectiveness of these drugs, making this the largest single cause of discontinuation apart from prescription expiry. Almost half of patients and physicians (46% in both categories) were not satisfied with OA treatment and only one patient in six regarded their overall health status during tNSAID therapy as satisfactory. Gastroprotective medications (GPMs) were prescribed for just over half the participating patients (51%), but use of these drugs appeared haphazard: 25% of those who received GPMs had no compelling indications for this therapy whereas more than half of the patients at high risk for gastrointestinal complications on the basis of clinical criteria were not receiving GPMs.

CONCLUSIONS

There is a high level of dissatisfaction with tNSAID therapy of OA, arising in large part from a perception among many patients and physicians that these drugs are not always adequately effective in relieving the symptoms of this disease. These findings, together with the low patient perceptions of general health, indicate the need for new therapeutic approaches to OA.

Celecoxib versus diclofenac and omeprazole in reducing the risk of recurrent ulcer bleeding in patients with arthritis

BACKGROUND

Current guidelines recommend that patients at risk for ulcer disease who require treatment for arthritis receive nonsteroidal antiinflammatory drugs (NSAIDs) that are selective for cyclooxygenase-2 or the combination of a nonselective NSAID with a proton-pump inhibitor. We assessed whether celecoxib would be similar to diclofenac plus omeprazole in reducing the risk of recurrent ulcer bleeding in patients at high risk for bleeding.

METHODS

We studied patients who used NSAIDs for arthritis and who presented with ulcer bleeding. After their ulcers had healed, we randomly assigned patients who were negative for Helicobacter pylori to receive either 200 mg of celecoxib twice daily plus daily placebo or 75 mg of diclofenac twice daily plus 20 mg of omeprazole daily for six months. The end point was recurrent ulcer bleeding.

RESULTS

In the intention-to-treat analysis, which included 287 patients (144 receiving celecoxib and 143 receiving diclofenac plus omeprazole), recurrent ulcer bleeding occurred in 7 patients receiving celecoxib and 9 receiving diclofenac plus omeprazole. The probability of recurrent bleeding during the six-month period was 4.9 percent (95 percent confidence interval, 3.1 to 6.7) for patients who received celecoxib and 6.4 percent (95 percent confidence interval, 4.3 to 8.4) for patients who received diclofenac plus omeprazole (difference, -1.5 percentage points; 95 percent confidence interval for the difference, -6.8 to 3.8). Renal adverse events, including hypertension, peripheral edema, and renal failure, occurred in 24.3 percent of the patients receiving celecoxib and 30.8 percent of those receiving diclofenac plus omeprazole.

CONCLUSIONS

Among patients with a recent history of ulcer bleeding, treatment with celecoxib was as effective as treatment with diclofenac plus omeprazole, with respect to the prevention of recurrent bleeding. Renal toxic effects are common in high-risk patients receiving celecoxib or diclofenac plus omeprazole.

Stratifying the risk of NSAID-related upper gastrointestinal clinical events: results of a double-blind outcomes study in patients with rheumatoid arthritis

BACKGROUND & AIMS

Epidemiologic data indicate that the risk of nonsteroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) clinical events varies based on patients' clinical characteristics. The authors determined risk factors for NSAID-related clinical upper GI events and the event rates, absolute risk reductions, and numbers needed to treat for individual risk factors for a nonselective NSAID and a selective cyclooxygenase 2 inhibitor in a double-blind outcomes trial.

METHODS

Eight thousand seventy-six rheumatoid arthritis patients aged >or=50 years (or >or=40 on corticosteroid therapy) were randomly assigned to rofecoxib 50 mg daily or naproxen 500 mg twice daily for a median of 9 months. The development of clinical upper GI events (bleeding, perforation, obstruction, and symptomatic ulcer identified on clinically indicated work-up) was assessed.

RESULTS

Significant risk factors included prior upper GI events, age >or=65, and severe rheumatoid arthritis (RR, 2.3-3.9). Patients administered naproxen who had prior upper GI complications or who were aged >or=75 years had 18.84 or 14.46 events per 100 patient-years, and the risk of events remained constant over time. The reduction in events with rofecoxib was similar in high- and low-risk subgroups (RR, 0.31-0.68). The number needed to treat with rofecoxib instead of naproxen to avert 1 GI event was 10-12 in highest risk patients (prior event, age >or=75 years, or severe rheumatoid arthritis), 17-33 in patients with other risk factors, and 42-106 in low-risk patients.

CONCLUSIONS

NSAID-related GI events increase dramatically with risk factors such as prior events or older age. Ten to twelve high-risk patients need to be treated with a protective strategy such as the selective cyclooxygenase 2 inhibitor, rofecoxib, to avert a clinical GI event.

Risk factors for anti-inflammatory-drug- or aspirin-induced gastrointestinal complications in individuals receiving outpatient physical therapy services

STUDY DESIGN

Prospective, multicenter, observational research study.

BACKGROUND

Minimal research exists that describes the potential for serious gastrointestinal complications in individuals receiving outpatient physical therapy care.

OBJECTIVE

To identify the prevalence of risk factors for gastrointestinal complications induced by anti-inflammatory drugs or aspirin in individuals receiving outpatient physical therapy services.

METHODS AND MEASURES

A self-administered questionnaire was used at 65 ambulatory physical therapy clinics to document past medical history, history of present illness, and medication use. Risk factors for anti-inflammatory-drug- or aspirin-induced gastrointestinal complications were identified and the proportion of patients reporting each factor was determined.

RESULTS

A total of 2433 patients completed the survey. Of the 2311 evaluable patients included in the study, 78.6% reported over-the-counter or prescribed use of an anti-inflammatory drug or aspirin during the week prior to the survey. Forty-nine percent of the patients reported at least 1 risk factor for drug-induced gastrointestinal complications, while 12.9% reported 2 or more risk factors. The most frequently reported established risk factors among anti-inflammatory drug or aspirin users were (1) combination (dual) therapy (22.3% reported concomitant use of anti-inflammatory and aspirin therapy), (2) advanced age (15.7% were over the age of 61 years), (3) history of peptic ulcer disease (7.8% had a history of peptic ulcer disease), and (4) significant systemic illness (6.8% reported having rheumatoid arthritis or heart disease). A frequently encountered risk factor combination was advanced age with a history of peptic ulcer disease (12.7%).

CONCLUSIONS

Patients seen at physical therapy ambulatory clinics present with multiple risk factors for anti-inflammatory-drug- or aspirin-induced gastrointestinal complications and provide a potential opportunity for risk reduction by clinicians working in this environment.

Treatment and prevention of aspirin-induced gastroduodenal ulcers and gastrointestinal bleeding

Aspirin use is associated with gastroduodenal mucosal damage and increased risk of upper gastrointestinal (GI) bleeding. Many aspirin users should receive prophylactic treatment since they often have several risk factors for upper GI complications. The best therapeutic approach for reducing GI toxicity in low-dose aspirin users is still ill-defined as only a few studies have focused on this problem. Omeprazole appears to be very effective in reducing both acute gastroduodenal mucosal damage and upper GI bleeding in the high-risk patient taking low-dose aspirin, but data with other anti-ulcer agents are lacking (misoprostol) or inconsistent (ranitidine) at present. The role of Helicobacter pylori is controversial in NSAID users, but there is now wide agreement that H. pylori infection increases mucosal damage and the risk of upper GI bleeding in low-dose aspirin users.

Underutilization of gastroprotective measures in patients receiving nonsteroidal antiinflammatory drugs

OBJECTIVE

To determine the frequency of use of recommended gastroprotective strategies in a cohort of patients receiving recurrent treatment with nonsteroidal antiinflammatory drugs (NSAIDs).

METHODS

A cross-sectional study was performed using administrative data from the Tennessee Medicaid (TennCare) program. The study population consisted of 76,765 recurrent recipients of NSAIDs (NSAID users), comprising 24% of the 319,402 persons ages 50 years or older enrolled in the TennCare program from January 1999 through June 2000. Frequency of use of either of 2 recommended gastroprotective strategies, involving either traditional NSAIDs combined with recommended anti-ulcer cotherapy or use of a selective cyclooxygenase 2-inhibiting drug (coxib), was measured and categorized by risk for ulcer complication.

RESULTS

Among this cohort of recurrent NSAID users, 16% received 1 of the 2 recommended gastroprotective therapies: 10% received traditional NSAIDs along with antiulcer drugs at the recommended doses and 6% received coxibs. Among those patients with > or=2 risk factors for ulcer complications (age 75 years or older, peptic ulcer or gastrointestinal bleeding in the past year, or concurrent use of oral anticoagulants or corticosteroids), 30% received such gastroprotective therapy.

CONCLUSION

Use of recommended strategies to decrease ulcer complications in vulnerable populations is relatively uncommon.

Dyspepsia: initial evaluation and treatment

OBJECTIVE

To provide recommendations for the initial evaluation and management of dyspepsia.

DATA SOURCES

Articles identified through a MEDLINE search for human studies published in English between 1966 and June 2001, using the primary search term dyspepsia and the secondary search terms diagnosis, complications, and treatment; textbooks with information on the diagnosis and management of gastrointestinal (GI) disorders; and bibliographies of retrieved publications and textbooks.

STUDY SELECTION

Articles that focused on dyspepsia as well as factors suggestive of more complicated GI disorders that would require pharmacists to refer patients to a physician.

DATA EXTRACTION

Performed by the author manually.

DATA SYNTHESIS

Functional dyspepsia (i.e., upset stomach or indigestion with no identifiable lesion) is a common complaint that may be relieved by medications, including antacids, histamine2-receptor antagonists, proton pump inhibitors, and promotility agents. However, therapy should not mask important warning signs and symptoms of more complicated diseases, as that could delay both diagnosis and more definitive treatment. Peptic ulcer disease and gastroesophageal reflux disease each account for about 20% of patients presenting with dyspepsia. Gastric cancer is an important disease to consider in the differential diagnosis of dyspepsia in patients older than 45 years, especially elderly patients (65 years and older).

CONCLUSION

Nonprescription medications can relieve functional dyspepsia, but pharmacists must be aware of common features of diseases that require patient referral to a physician for further evaluation.

Chemoprevention of esophageal adenocarcinoma by COX-2 inhibitors in an animal model of Barrett's esophagus

BACKGROUND & AIMS

Carcinogenesis in Barrett's esophagus (BE) is associated with an increased expression of cyclooxygenase (COX) 2. However, there has been no direct evidence that inhibition of COX-2 prevents cancer in BE. We studied the effect of MF-Tricyclic, a selective COX-2 inhibitor, on the development of BE and adenocarcinoma in a rat model.

METHODS

Four weeks after esophagojejunostomy, 105 Sprague-Dawley rats were randomized to a chow containing MF-Tricyclic or Sulindac, or a placebo. Ninety-six (92%) rats completed the study and were sacrificed at 28 +/- 2 weeks. The animals were assessed for the presence of cancer, tumor volume, BE, degree of inflammation, and COX-2 expression and activity.

RESULTS

MF-Tricyclic and Sulindac reduced the relative risk of development of esophageal cancer by 55% (95% confidence interval [CI] = 43%-66%, P < 0.008) and by 79% (95% CI = 68%-87%, P < 0.001), respectively, compared with controls. No significant differences were noted in the risk of esophageal cancer between the MF-Tricyclic and the Sulindac group (P = 0.34). The median tumor volume was not significantly different among the 3 groups (P = 0.081). Moderate to severe degree of inflammation was significantly more common (P = 0.005) in the control compared with the MF-Tricyclic and the Sulindac group; however, the prevalence of BE was not significantly different between groups (P = 0.98). Rats in the control group had higher tissue PGE2 level compared with the MF-Tricyclic and Sulindac groups (P = 0.038).

CONCLUSIONS

Selective and nonselective COX-2 inhibitors can inhibit inflammation, COX-2 activity, and development of adenocarcinoma induced by reflux. This provides direct evidence that COX-2 inhibitors may have chemopreventive potential in BE.

An evidence-based evaluation of the gastrointestinal safety of coxibs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are nonselective inhibitors of cyclooxygenase (COX) isoforms COX-1 and COX-2. NSAIDs have analgesic and anti-inflammatory properties that are proven, and they are extensively used in the treatment of arthritis, pain, and headache. Despite their good efficacy, NSAIDs are associated with significant gastrointestinal (GI) toxicity, which appears to be related to the inhibition of the cytoprotective function of COX-1. Thus, selective COX-2 inhibitors, or coxibs, were designed to inhibit only the production of COX-2-dependent inflammatory prostaglandins, without any effect on COX-1 and its gastroprotective function. This article reviews important evidence on the GI safety of coxibs. Endoscopic studies demonstrated that coxibs, such as celecoxib and rofecoxib, induced significantly fewer ulcers than nonspecific NSAIDs. To analyze whether the incidence of clinical GI events is also lower with coxibs, 2 large controlled clinical trials, the Celecoxib Long-term Arthritis Safety Study (CLASS) and Vioxx Gastrointestinal Outcomes Research (VIGOR), evaluated the GI safety of celecoxib and rofecoxib, respectively. Based on evidence from the VIGOR trial, it was demonstrated that rofecoxib has already fulfilled the promise and significantly decreases the risk of clinically important and complicated GI events compared with a nonselective NSAID, naproxen. In contrast, the CLASS trial showed that the incidence of ulcer complications in patients treated with celecoxib was similar in patients treated with nonspecific NSAIDs.

Use of nonopioid analgesics and adjunctive agents in the management of pain in rheumatic diseases

Antirheumatic analgesic medications generally fall into one of the following categories: acetaminophen, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), tramadol, traditional opioids, or adjunctive analgesics. This article does not discuss corticosteroids, opioids, or topical analgesics. Acetaminophen, usually indicated early for mild pain, is often used in combination with other drugs. It has established safety. Traditional NSAIDs are effective in relieving moderate pain in certain inflammatory and noninflammatory conditions. There are many effective choices, but as a class it is fraught with the risk of serious peptic ulcer disease and its complications. Cyclooxygenase-2 specific inhibitors are NSAIDS that reduce the gastrointestinal risk and platelet-mediated bleeding. All NSAIDs may produce peripheral edema, hypertension, and potentiate warfarin. The evidence that coxibs cause thrombotic heart disease is weak. Tramadol is an alternative to musculoskeletal pain management, particularly in patients with moderate to moderately severe pain who do not respond to or who cannot tolerate acetaminophen, NSAIDs, or opioids. The role of analgesic adjuvants is discussed.

Helicobacter pylori, NSAIDs and gastrointestinal haemorrhage

Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs) cause the majority of bleeding ulcers. Whether the presence of H. pylori infection would affect the risk of ulcers in patients taking NSAIDs is important for both theoretical and practical reasons. However, the results have been so conflicting that there is no consensus on the management of patients requiring NSAIDs who are infected with H. pylori. The controversy is largely due to the variable study design and marked heterogeneity of the study population. Studying the interaction between H. pylori and NSAIDs without considering these factors often leads to erroneous conclusions. Current evidence suggests that H. pylori contributes to an increased ulcer risk for patients who are about to start NSAID treatment, whereas NSAIDs probably account for the majority of ulcer disease in patients who are already taking long-term NSAIDs. In the light of the reduced gastric toxicity of COX-2 inhibitors, the relative importance of H. pylori in the pathogenesis of ulcers is expected to increase. Furthermore, recent evidence suggests that H. pylori contributes to ulcer bleeding associated with low-dose aspirin. Among H. pylori-positive patients with a history of ulcer bleeding who are taking low-dose aspirin, the eradication of H. pylori has been shown to be comparable to omeprazole in preventing recurrent bleeding.

Patient and physician satisfaction with aceclofenac: results of the European Observational Cohort Study (experience with aceclofenac for inflammatory pain in daily practice). Aceclofenac is the treatment of choice for patients and physicians in the management of inflammatory pain

A pan-European study involving 23407 patients with pain due to various inflammatory or degenerative rheumatic diseases was undertaken in Austria, Belgium, Germany and Greece, to evaluate overall pain relief and satisfaction with aceclofenac therapy. Aceclofenac was considered by patients to be a highly efficacious treatment with excellent and fast analgesic activity that was maintained throughout the study period. At the conclusion of the study, assessment of patient status, a parameter encompassing both efficacy against inflammatory pain and tolerability, by both patient and physician, was either much improved or improved in 84% of cases. These evaluations were similar irrespective of the country or whether the indication was acute (e.g. post-pain) or chronic pain (e.g. osteoarthritis). Patient satisfaction with, and compliance of, aceclofenac therapy was similarly impressive; 90% of patients were satisfied and over 90% of patients were treatment compliant. In combination with the recently published SAMM study results, the findings of the European Observational Cohort study validate aceclofenac, in everyday clinical practice, as an effective, well-tolerated and well-accepted therapy for both acute and chronic inflammatory and degenerative disease. The availability of a powerful anti-inflammatory agent with a low incidence of side-effects is of considerable value to both the patient and physician in the management of inflammatory pain. This objective has been fulfilled with aceclofenac therapy.

Dietary antioxidants protect gut epithelial cells from oxidant-induced apoptosis

BACKGROUND

The potential of ascorbic acid and two botanical decoctions, green tea and cat's claw, to limit cell death in response to oxidants were evaluated in vitro.

METHODS

Cultured human gastric epithelial cells (AGS) or murine small intestinal epithelial cells (IEC-18) were exposed to oxidants - DPPH (3 microM), H2O2 (50 microM), peroxynitrite (300 microM) - followed by incubation for 24 hours, with antioxidants (10 microg/ml) administered as a 1 hour pretreatment. Cell number (MTT assay) and death via apoptosis or necrosis (ELISA, LDH release) was determined. The direct interactions between antioxidants and DPPH (100 microM) or H2O2 (50 microM) were evaluated by spectroscopy.

RESULTS

The decoctions did not interact with H2O2, but quenched DPPH although less effectively than vitamin C. In contrast, vitamin C was significantly less effective in protecting human gastric epithelial cells (AGS) from apoptosis induced by DPPH, peroxynitrite and H2O2 (P < 0.001). Green tea and cat's claw were equally protective against peroxynitrite and H2O2, but green tea was more effective than cat's claw in reducing DPPH-induced apoptosis (P < 0.01). Necrotic cell death was marginally evident at these low concentrations of peroxynitrite and H2O2, and was attenuated both by cat's claw and green tea (P < 0.01). In IEC-18 cells, all antioxidants were equally effective as anti-apoptotic agents.

CONCLUSIONS

These results indicate that dietary antioxidants can limit epithelial cell death in response to oxidant stress. In the case of green tea and cat's claw, the cytoprotective response exceed their inherent ability to interact with the injurious oxidant, suggestive of actions on intracellular pathways regulating cell death.

Gastrointestinal toxicity associated with nonsteroidal anti-inflammatory drugs. Epidemiologic and economic issues

The large body of literature on the gastrointestinal side effects of NSAIDs has shown consistently that populations can be identified that have a markedly elevated risk for these iatrogenic conditions. These groups include the elderly, persons with prior history of peptic ulcer disease and its complications, persons receiving anticoagulant and corticosteroid therapy, and persons who require long-term NSAID therapy, especially at high dose. It is possible that several comorbidities (e.g., rheumatoid arthritis) predispose patients to gastrointestinal complications caused by NSAIDs, but few studies have adjusted carefully for the possibility that concomitant medication use (e.g., oral anticoagulants, corticosteroids) or increased NSAID dose may account best for apparent association of comorbidities as a risk factor for serious gastrointestinal events. The role of H. pylori infection in affecting the risk of complicated ulcer disease among NSAID users remains to be fully elucidated. Low-dose aspirin for cardioprotective use is associated with an increased risk for PUBs; when used concomitantly with NSAIDs, this increases the risk of PUBs above that of the NSAID itself. Apart from the physical toll NSAID-related gastrotoxicity places on the patient, there are considerable economic consequences to patients, providers, and society. This cost presents a subject for research for those interested not only in improving the quality of patient care, but also in the prudent use of health care resources.

Gastrointestinal afferents as targets of novel drugs for the treatment of functional bowel disorders and visceral pain

An intricate surveillance network consisting of enteroendocrine cells, immune cells and sensory nerve fibres monitors the luminal and interstitial environment in the alimentary canal. Functional bowel disorders are characterized by persistent alterations in digestive regulation and gastrointestinal discomfort and pain. Visceral hyperalgesia may arise from an exaggerated sensitivity of peripheral afferent nerve fibres and/or a distorted processing and representation of gut signals in the brain. Novel strategies to treat these sensory bowel disorders are therefore targeted at primary afferent nerve fibres. These neurons express a number of molecular traits including transmitters, receptors and ion channels that are specific to them and whose number and/or behaviour may be altered in chronic visceral pain. The targets under consideration comprise vanilloid receptor ion channels, acid-sensing ion channels, sensory neuron-specific Na(+) channels, P2X(3) purinoceptors, 5-hydroxytryptamine (5-HT), 5-HT(3) and 5-HT(4) receptors, cholecystokinin CCK(1) receptors, bradykinin and prostaglandin receptors, glutamate receptors, tachykinin and calcitonin gene-related peptide receptors as well as peripheral opioid and cannabinoid receptors. The utility of sensory neuron-targeting drugs in functional bowel disorders will critically depend on the compounds' selectivity of action for afferent versus enteric or central neurons.

Incremental cost-effectiveness analysis comparing rofecoxib with nonselective NSAIDs in osteoarthritis: Ontario Ministry of Health perspective

BACKGROUND

Clinical trials have shown rofecoxib, a selective inhibitor of cyclo-oxygenase-2, to be associated with fewer gastrointestinal complications than non-selective nonsteroidal anti-inflammatory drugs (NSAIDs).

OBJECTIVE

To evaluate the potential clinical and economic consequences of rofecoxib prescription in Ontario, Canada, for patients with osteoarthritis (OA) aged >65 years who did not respond to paracetamol (acetaminophen) therapy.

DESIGN

Decision analytic modelling study.

METHODS

A model was constructed to compare rofecoxib and nonselective NSAIDs with respect to their gastrointestinal complications in patients with OA. The model had a 1-year horizon and considered direct medical costs from the perspective of the Ontario Ministry of Health. Event rates were estimated from a pooled analysis of 8 phase IIb/Ill clinical trials. The number of perforations, ulcers and bleeds (PUBs) with each strategy was used as the primary measure of effectiveness.

RESULTS

In the base-case scenario, the expected total cost per patient-day on nonselective NSAIDs was 1.60 Canadian dollars (Can dollars) versus 1.67 Can dollars on rofecoxib (1999 values). Rofecoxib was associated with 0.0109 fewer PUBs per patient per year. The incremental cost to avoid 1 additional PUB by substituting rofecoxib for nonselective NSAIDs was 2247 Can dollars. The rofecoxib strategy became dominant if a gastroprotective agent was prescribed to more than 27.5% of the patients receiving nonselective NSAIDs.

CONCLUSION

For patients with OA aged >65 years in whom paracetamol therapy has failed, rofecoxib may represent a cost-effective alternative to nonselective NSAIDs. Increased costs for drug acquisition are offset, in part. by avoidance of gastrointestinal complications and reduced use of gastroprotective agents. Rofecoxib may offer increased benefit among patients at a higher risk of serious gastrointestinal events.