Lick the Stomach and Bite the Heart?

Abstract

tomatic ulcers for celecoxib versus NSAIDs were 2.01 versus 2.12% (p = 0.92) and 4.70 versus 6.00% (p = 0.49) [3] . The TARGET study (Therapeutic Arthritis Research and Gastrointestinal Event Trial) claimed that the risk of cardiovascular events was comparable among lumiracoxib, naproxen and ibuprofen. Patients in TARGET were 50 years old or older, but the study excluded patients with myocardial infarction, stroke, coronary artery bypass surgery, or congestive heart failure [4] . Less than 2% of the patients had a previous myocardial infarction or a revascularization procedure. Unfortunately, this trial, like all others in the clinical development of coxibs, did not refl ect the general population but excluded patients with known preexisting coronary artery disease. In practice, osteoarthritis frequently coexists with coronary artery disease. The reduction in the protective effect of aspirin on coronary events when coadministered with coxibs has also not been suffi ciently analyzed. In the case of patients taking low-dose aspirin, it is unnecessary to add coxibs; there is no benefi t in the reduction of ulcer complications. Moreover, questions regarding the risk of myocardial infarction remain unanswered despite polypharmacy. The review by Otterstad [1] addresses a well-known controversy about Cox-2 inhibitors and cardiovascular risk, but leaves clinical questions unanswered in the light of the Vioxx withdrawal. The main reason why clinicians choose Cox-2 inhibitors is because of their relatively lesser side effects on the gastric mucosa. In osteoarthritis patients with a risk of cardiovascular events, low-dose aspirin is advised by some clinicians along with Cox-2 inhibitors like celecoxib and lumiracoxib. This combination effectively nullifi es the benefi t of Cox-2 inhibitors on the gastrointestinal (GI) system. Low-dose aspirin also carries a risk of GI bleed [2] . The question is how many of us would use two NSAIDs for two different indications or use one NSAID for two different indications? It would be more benefi cial if these patients were prescribed aspirin at doses of 1,000 mg per day in combination with proton pump inhibitors to confer protection against cardiovascular events and GI symptoms in addition to pain relief in osteoarthritis. In the CLASS study (Celecoxib Longterm Arthritis Safety Study), for patients taking aspirin with celecoxib, the annualized incidence rates of upper GI ulcer complications alone and combined with sympPublished online: January 27, 2005