Volume 180 - Issue 6
Lessons from early large-scale adoption of celecoxib and rofecoxib by Australian general practitioners
Author: John S Dowden
Med J Aust 2004; 180 (6): 310-312. || doi: 10.5694/j.1326-5377.2004.tb05940.x
Published online: 15 March 2004
Published online: 15 March 2004
John S Dowden
Editor in Chief, Australian Prescriber, Suite 3/2 Phipps Close, Deakin, ACT 2600. jdowdenATnps.org.au
In reply: The general practitioners’ decision to prescribe COX-2 inhibitors was rational, but the information underpinning their decision was less than independent. A big reduction in short-term relative risk can be persuasive, even if the absolute benefit is small.
General practitioners deal with whole patients, so they consider the overall risks of treatment, and not just one adverse effect. While COX-2 inhibitors may have gastrointestinal advantages, they may have cardiovascular disadvantages.
Treatments for chronic conditions should be based on long-term data. The observation that most of the ulcer complications in the second half of the CLASS study were in patients taking celecoxib is therefore important.1
Undoubtedly, some patients who could not take non-selective non-steroidal anti-inflammatory drugs (NSAIDs) were able to tolerate COX-2 inhibitors. However, Kerr et al found that up to 61% of patients given a COX-2 inhibitor had not previously been prescribed any analgesia.2 It seems unlikely that so many people suddenly required analgesia that only a COX-2 inhibitor could provide.
The Pfizer-funded study by MacDonald et al shows that UK general practitioners tended to prescribe COX-2 inhibitors for patients at risk of gastrointestinal haemorrhage.3 This follows the advice of the National Institute of Clinical Excellence (NICE). However, NICE also recommended against the routine use of COX-2 inhibitors.4 A review by the Canadian Co-ordinating Office for Health Technology Assessment has also concluded that COX-2 inhibitors may have no significant safety advantage over diclofenac.5
Solomon et al conclude that the cost of adverse effects of NSAIDs in low-risk elderly patients is modest.6 However, there is no comparison with COX-2 inhibitors, so we do not know if they reduce this cost. Hospital accountants may be interested to know that researchers at the Mayo Clinic concluded that, in terms of averting gastrointestinal events, the most cost-effective analgesic is paracetamol.7
Competing interests
Australian Prescriber is published by the National Prescribing Service. John Dowden is an unpaid director of Therapeutic Guidelines Ltd, and a member of the Editorial Advisory Board of the Australian Medicines Handbook.
References
- Juni P, Rutjes AW, Dieppe PA. Are selective COX-2 inhibitors superior to traditional non-steroidal anti-inflammatory drugs? BMJ 2002; 324: 1287-1288. CHDDDHFH
- Kerr SJ, Mant A, Horn FE, et al. Lessons from early large-scale adoption of celecoxib and rofecoxib by Australian general practitioners. Med J Aust 2003; 179: 403-407. <eMJA full text>
- MacDonald T, Morant S, Goldstein J, et al. Chanelling bias and the incidence of gastrointestinal haemorrhage in users of meloxicam, coxibs, and older, non-specific non-steroidal anti-inflammatory drugs. Gut 2003; 52: 1265-1270. CHDIGBAB
- National Institute for Clinical Excellence. Guidance on the use of cyclo-oxygenase (COX) II selective inhibitors, celecoxib, rofecoxib, meloxicam and etodolac for osteoarthritis and rheumatoid arthritis. London: NICE, 2001. CHDHIIAH
- Rostom A, Dube C, Jolicoeur E, et al. Gastroduodenal ulcers associated with the use of non-steroidal anti-inflammatory drugs: a systematic review of preventive pharmacological interventions. Ottawa: Canadian Coordinating Office for Health Technology Assessment, 2003. CHDFFBCG
- Solomon DH, Glynn RJ, Bohn R, et al. The hidden cost of non-selective non-steroidal anti-inflammatory drugs in older patients. J Rheum 2003; 30: 792-798. CHDGHHGG
- Kamath CC, Kremers M, Vanness DJ, et al. The cost-effectiveness of acetaminophen, NSAIDs, and selective COX-2 inhibitors in the treatment of symptomatic knee osteoarthritis. Value in Health 2003; 6: 144-157. CHDCICAH