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

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Clinical Inquiries

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

J Fam Pract. 2006 March;55(3):260-262

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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.

3. Silverstein FE, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: A randomized controlled trial. Celecoxib Long-term Arthritis Safety Study. JAMA 2000;284:1247-1255.

4. Towheed TE, Judd MG, Hochberg MC, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev 2003;(2):CD004257.-

5. Garner SE, Fidan DD, Frankish RR, Maxwell LJ. Rofecoxib for osteoarthritis. Cochrane Database Syst Rev 2005;(1):CD005115.-

6. Garner S, Fidan D, Frankish R, et al. Celecoxib for rheumatoid arthritis. Cochrane Database Syst Rev 2002;(4):CD003831.-

7. Garner SE, Fidan DD, Frankish RR, et al. Rofecoxib for rheumatoid arthritis. Cochrane Database Syst Rev 2005;(1):CD003685.-

8. Silverstein FE, Graham DY, Senior JR, et al. Misoprostol reduced serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 1995;123:241-249.

9. Bresalier RS, Sandler RS, Quan H, et al. Cardiovascular events associated with rofecoxib in a colorectal adenoma chemoprevention trial. N Engl J Med 2005;352:1092-1102.

10. Solomon SD, McMurray JJ, Pfeffer MA, et al. Cardiovascular risk associated with celecoxib in clinical trial for colorectal adenoma prevention. N Engl J Med 2005;352:1071-1080.

11. Derry S, Loke YK. Risk of gastrointestinal haemorrhage with long term use of aspirin: meta-analysis. BMJ 2000;321:1183-1187.

12. Laine L, Maller ES, Yu C, Quan H, Simon T. Ulcer formation with low-dose enteric-coated aspirin and the effect of COX-2 selective inhibition: A double-blind trial. Gastroenterology 2004;127:395-402.

13. Simon LS, Lipman AG, Jacox AK, et al. Pain in Osteoarthritis, Rheumatoid Arthritis and Juvenile Chronic Arthritis. 2nd ed. Glenview, Ill: American Pain Society; 2002.

14. American College of Rheumatology (ACR) Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000;43:1905-1915.

15. American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum 2002;46:328-346.

16. Managing Osteoarthritis: Helping the Elderly Maintain Function and Mobility. Issue 4, AHRQ Pub. No 02-0023, May 2002. Agency for Healthcare Research and Quality. Available at: www.ahrq.gov/research/osteoria/osteoria.htm#self-manage.

TABLE 1
Prediction of serious gastrointestinal bleeding

RISK FACTORS PRESENT	RISK OF GI BLEEDING
0 factor	0.4 %
Any 1 factor	1.0 %
All 4 factors	9.0 %
Risk factors include age >75 years, history of peptic ulcer disease, history of gastrointestinal bleeding, history of cardiovascular disease
Source: Silverstein et al, Ann Intern Med 1995.⁸

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.

FAST TRACK

Select patients for COX-2 inhibitors by considering risks:

CV disease
GI bleeding
renal disease
patient preference
cost

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.

TABLE 2
Risk factors for upper gastrointestinal adverse events

Age ≥65 years
Comorbid medical conditions
Oral glucocorticoids
History of peptic ulcer disease
History of upper gastrointestinal bleeding
Anticoagulants
Source: American College of Rheumatology, Arthritis Rheum 2000.¹²

Evidence-based answers from the Family Physicians Inquiries Network