Which Is Better: COX2 or NSAID Plus PPI?
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville
Dr. Kuritzky is a consultant for Abbott, AstraZeneca, Boehringer Ingelheim, Daiichi, Sankyo, Forest Pharmaceuticals, Lilly, Novo Nordisk, and Takeda. Editor Stephen Brunton, MD, Adjunct Clinical Professor, University of North Carolina, Chapel Hill, is a consultant for Amylin, Novo Nordisk, Shionogi Pharma, Takeda, and Teva; he serves on the speaker's bureau of Boehringer Ingelheim, Novo Nordisk, and Teva. Peer reviewer Gerald Roberts, MD, Assistant Clinical Professor of Medicine, Albert Einstein College of Medicine, New York, NY, reports no financial relationships to this field of study.
This article originally appeared in the September 15, 2010 issue of Internal Medicine Alert.
Source: Chan FK, et al. Celecoxib versus omeprazole and diclofenac in patients with osteoarthritis and rheumatoid arthritis (CONDOR). Lancet 2010;376:173-179.
The GI toxicity of NSAIDs is well recognized, with a 1998 report suggesting that as many as 16,500 deaths that year were attributable to NSAID-induced GI bleeding. One of the reputed benefits of the development of cyclo-oxygenase selective NSAIDs was the belief that their relative lack of effect on COX1 would obviate much of the GI toxicity seen. Some patients will continue to use maintenance therapy with anti-inflammatory agents for protracted periods; hence, determination of which GI protection technique is most beneficial is a critical issue. To that end, Chan et al studied Helicobacter-negative patients with osteoarthritis and/or rheumatoid arthritis (n = 4484) to compare GI adverse events (the primary outcome) seen with celecoxib vs. a traditional NSAID (diclofenac) plus proton pump inhibitor (PPI) (omeprazole). Utilization of aspirin was a study exclusion.
At 180 days, the celecoxib group showed a statistically significantly lesser GI event rate than the diclofenac plus omeprazole group (0.9 % vs 3.8%). Tolerability, as measured by treatment discontinuation, of celecoxib (200 mg bid) was superior to diclofenac 75 mg bid plus omeprazole 20 mg qd (6% vs 8%).
For patients requiring maintenance anti-inflammatory treatment, GI consequences of celecoxib are fewer than if a traditional NSAID is combined with a proton pump inhibitor, although cost considerations may preclude universal application of this preferred treatment.
The GI toxicity of NSAIDs is well recognized, with a 1998 report suggesting that as many as 16,500 deaths that year were attributable to NSAID-induced GI bleeding.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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