Lessons from early large-scale adoption of celecoxib and rofecoxib by Australian general practitioners

To the Editor: In their article on adoption of celecoxib and rofecoxib by Australian general practitioners, Kerr et al noted that “the increase in COX-2 [cyclooxygenase-2] prescribing coincided with a period of energetic marketing to the medical profession, which promoted the message that the new C2SNs [COX-2-selective non-steroidal anti-inflammatory drugs] were ‘safer’ than traditional NSAIDs [non-steroidal anti-inflammatory drugs].”1 The implication is that the decision of Australian GPs to prescribe these new drugs may have been less than independent or rationally informed.

The reason for prescribing C2SNs is that, like traditional NSAIDs, they relieve arthritic pain and so promote mobility, although, unlike traditional NSAIDs, they do not inhibit cyclooxygenase-1. While the power of advertising is undeniable, the simple message about C2SNs is that there is an approximate 50% reduction in clinically significant gastrointestinal (GI) complications compared with traditional NSAIDs.2 There are over a dozen articles to support the better GI side-effect profile of C2SNs. Most data support a non-cumulative, reversible, but constant, risk of peptic and other, more distal GI bleeds, or perforation, with the coefficient of risk being significantly greater for NSAIDs.3 Although the data from the CLASS study did suggest that the higher GI morbidity of NSAIDs seemed to diminish with time,4 that of celecoxib remained at a constantly lower rate.5 This is clinically important for all our patients, and especially for our ageing population with their comorbid conditions and polypharmacy. I suggest that it is for this single reason that many doctors have been quick to take up C2SNs for their patients. The better GI safety enfranchised patients who previously could not take NSAIDs safely, and could explain why the overall anti-inflammatory market increased by 20%.1

However, no one suggests that the C2SNs are free of non-GI side-effects. To the best of my knowledge, COX-2-specific NSAIDs have not been promoted as being free of non-GI side-effects or better than COX-1-specific NSAIDs in this regard.

While agreeing with the last sentence of Dowden’s editorial that “new is not always better”,3 the opposite — that “new is sometimes better” — is also true. Thus, we persuaded the accountants in our hospital, who rightly participate in the determination of which drugs are available on its formulary, to accept one of the COX-2 drugs because of its better GI complication profile. While this will not reduce its pharmacy budget, it is anticipated to reduce overall hospital costs in this area,5 which should allow a reapportionment of its budget to other areas of need. Of course, the hospital is watching carefully for any unforeseen “serious adverse effects which sometimes only emerge after marketing”.3