With so many pain relievers available, choosing the right one for you can seem very confusing. All medications can have potential side effects and the risks and benefits must be weighed in each individual. It is best to speak with your doctor to see which one is best for you.
What are COX-2 nonsteroidal anti-inflammatory medications (NSAIDs)?
The COX-2 inhibitors represent a new class of NSAIDs, which are designed to reduce pain and inflammation just like traditional NSAIDs. However, COX-2 inhibitors have an added safety benefit of being less likely to cause stomach problems such as ulcers, bleeding, and obstruction. Both COX-2 inhibitors and NSAIDs have equal ability to control pain and inflammation.
How do COX-2 NSAIDS work?
Traditional NSAIDs such as aspirin, Ibuprofen, naproxen, and others act by blocking the production of a family of chemicals (known as prostaglandins) that cause inflammation. There are 2 enzymes that are important for allowing prostaglandins to cause inflammation, specifically known as COX-1 and COX-2 enzymes.
Traditional NSAIDs work by blocking both COX-1 and COX-2. The COX-2 inhibitors work by blocking the COX-2 enzyme
only
. By blocking the COX-2 enzyme, these new drugs can help to block pain and inflammation and still allow the COX-1 enzyme to work. This is important because the COX-1 enzyme is needed to help protect the stomach lining and decrease your chance of having a stomach ulcer and/or bleeding. Thus, the new COX-2 inhibitors can help relieve pain and inflammation with the added benefit of protecting your stomach
What are the new COX-2 inhibitors?
There is only one COX-2 inhibitor at the present time, namely celecoxib (Celebrex).
Both rofecoxib (Vioxx) and valdecoxib (Bextra) have been removed from the market due to concerns about an excess of heart attacks or stroke. Similarly, Valdecoxib was suspended by Pfizer when the FDA found an increased rate of heart problems as well as an increased rate of rare, serious skin reactions.
How are COX-2 inhibitors safer than traditional NSAIDs?
Over the past two years there have been numerous studies documenting the enhanced safety profile of COX-2 inhibitors over traditional NSAIDs. Two recently completed large clinical trials known as the CLASS study for celecoxib, and the VIGOR study for rofecoxib, collectively investigated over 10,000 patients. Both of these studies demonstrated that these drugs are significantly better than traditional drugs such as naproxen (Naprosyn); diclofenac (Voltaren); and ibuprofen (Motrin), in reducing the risk for most stomach problems such as ulcerations, perforations, or bleeding. These drugs do not eliminate this possibility, but dramatically and significantly reduce it.
In addition, COX-2 inhibitors do not significantly inhibit blood clotting, and thus patients who are at risk for bleeding such as those taking anticoagulants or going to surgery may more safely take these drugs than traditional NSAIDs. It is still important to note that if a patient is on an oral anticoagulant such as coumadin, they need to have their blood monitored when starting one of these agents to ensure it is not altered.
Are COX-2 inhibitors as effective as traditional NSAIDs?
The answer to this, quite clearly, is yes. It is important to realize, however, that celecoxib is not any more potent at relieving pain or inflammation than traditional NSAIDs. They are merely a safer alternative in those patients with increase risk of stomach ulcers and/or bleeding.
How are COX-2 inhibitors prescribed?
Celecoxib (Celebrex) is prescribed as 100 mg or 200 mg capsules and can be dosed either once a day or twice a day. The general dose for osteoarthritis is 100 or 200 mg a day and the dose for rheumatoid arthritis is 200 mg up to twice a day.
Can COX-2 inhibitors be taken like aspirin to protect a person from a heart attack or a stroke?
The answer to this is no, because these drugs do not interfere with blood clotting as aspirin does. COX-2 inhibitors may be taken with aspirin, but even this small dose places the individual at risk for aspirin-related stomach toxicity and bleeding.
Does everyone who takes NSAIDs need to be on a COX-2 inhibitor?
The answer to this is no because the risk from traditional NSAIDs is low for most individuals. Those who stand to benefit most from COX-2 inhibitors include those who are at increased risk for stomach complications and bleeding. (See below)
Do COX-2 inhibitors have similar side effects to traditional NSAIDs?
Yes, aside from the enhanced safety profile to the stomach lining and reduced bleeding tendencies mentioned above, they have the same common side effects noted for traditional NSAIDs. These include an increased chance of heart attack or stroke, rare liver and kidney problems, headaches and dizziness, allergic reactions and rashes. NSAIDs, including COX-2 inhibitors, should not be used during or immediately after a heart procedure called coronary artery bypass graft (CABG).
Please note: The side effects listed are the most common. All possible side effects are not included. Always contact your health care provider if you have questions about your particular medication. Patients with significant renal disease should not take NSAIDS.
How can I minimize my chances of a side effect from NSAIDs?
NSAID medicines should only be used exactly as prescribed. It is safest to use NSAIDs at the lowest possible dose and for the shortest time needed for your treatment.
Please note that the chance of a person getting an ulcer or bleeding increases with the following:
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Older age > 60 years old
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Previous history of stomach ulcer disease
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Active smoker
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Drinking alcohol
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Concurrent use of prednisone or blood thinning medication
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Poor health or multiple medical problems
Can I take a COX-2 inhibitor if I am being treated for high blood pressure?
All NSAIDs, including COX-2 inhibitors, can raise blood pressure in some people.. Patients with high blood pressure who are starting any form of NSAID therapy should have their blood pressure monitored carefully. If blood pressure increases in spite of regularly taking their blood pressure medications, your doctor might consider stopping or changing your NSAID.
As with any medication, always follow the directions on the label and the instructions from your health care provider. It is not recommended to combine a COX-2 inhibitor with a traditional NSAID other than low dose aspirin, because all the advantages of safety will be lost.
October 27, 2006
