INFO - Cardiac Patients With Arthritis: Advice For The Post-Vioxx Era

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Cardiac Patients With Arthritis: Advice For The Post-Vioxx Era

Nov. 12, 2004

By H. Lee, M.D.

Brigham and Women's Hospital

For the patient who has heart disease, or who is worried that he or she may

be at risk of it, the question that remains after all the news articles

about Vioxx is a simple one: What am I supposed to do about my aches and

pains?

Should you switch to another COX-2 inhibitor such as Celebrex or Bextra?

Take a COX-2 with baby aspirin to provide protection against heart attacks?

The guidelines from expert groups are, to put it politely, " in evolution. "

In the meantime, my advice is - dodge the question. I'll get to that in a

few paragraphs, but first let's go over key background facts:

COX-2 inhibitors such as Vioxx and Celebrex do NOT provide any greater

pain relief than older and much less expensive nonsteroidal

anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin and

others) and naproxen (Aleve, Naprosyn and others). Some people respond

better to one drug or another, but no self-respecting expert asserts that

the COX-2s are " better " pain relievers.

The advantage of the COX-2 inhibitors is that they cause less

irritation of the stomach lining, and also do not slow the action of

blood-clotting cells called platelets - and therefore, in theory, should be

less likely to cause bleeding ulcers. In real life, this " advantage " is very

small, and far from complete. The risk of serious bleeding is only 1 percent

to 2 percent per year among people using the older NSAIDs, and COX-2s reduce

this risk to 0.5 percent to 1 percent per year.

There are two reasons why COX-2s can be hard on your heart. First,

like all NSAIDs, including ibuprofen and naproxen, the COX-2s cause your

kidneys to hold onto to water, and can make your blood pressure go up -

straining your heart.

More worrisome for COX-2 users is evidence that these agents might

actually encourage platelets to clump together - thereby raising risk of

heart attack and stroke.

Vioxx has been pulled from the market because a marked increase in

heart-attack rate was found among its users in a trial in which it was being

compared with a placebo.

Celebrex and other COX-2s have NOT been found to cause an increased

risk of heart attacks - but most trials of the other COX-2s allowed patients

to take aspirin, which would be expected to block the potentially dangerous

effects of COX-2s on platelets.

Aspirin irritates the stomach and reduces the gastrointestinal

benefits of COX-2s.

Given all this information, I try to avoid using COX-2s at all in patients

with heart disease - or who have an increased risk of heart attack because

of diabetes, hypertension, high cholesterol, smoking or other risk factors.

There is a pretty good chance that the other COX-2s such as Celebrex do not

have the same hazardous effects as Vioxx. However, as a recent Perspective

article in The New England Journal of Medicine summarized, the burden of

proof now rests with those who claim that this is a problem for Vioxx alone.

Hashing out that scientific issue will take years, and your back is hurting

you right now! So here is an approach that is safe, effective, and may

actually save you some money.

Forget about COX-2s such as Celebrex unless you have tried everything

else, and it is the only drug that relieves your pain. I can't explain why

that might be the case, but there are some patients who clearly state they

get more pain relief from Celebrex or Bextra. Perhaps the television ads

influence the positive response. Whatever the reality, I respect my

patients'

experiences regarding what gives them the most pain relief.

For everyone else, first try acetaminophen (Tylenol) for your back and

joint pains. This drug is cheap, safe and effective for an amazing

percentage of problems. Don't drink heavily if you use it regularly - but,

then again, don't drink heavily even if you don't!

If acetaminophen doesn't do the job, try an over-the-counter or

generic prescription agent such as ibuprofen or naproxen. Be sure your

doctor knows what you are up to, because these can raise your blood pressure

and affect your kidney function - just like the COX-2s.

If you have factors that put you at higher risk of stomach and

intestinal complications such as internal bleeding, you should avoid

non-selective older NSAIDs if possible. If you absolutely need to take an

NSAID such as ibuprofen or naproxen, then I recommend also taking a proton

pump inhibitor (PPI). The PPI blocks stomach acid and protects the lining.

Over-the-counter Prilosec or generic omeprazole can do the job, usually with

less of a hit to your pocketbook than a prescription for a COX-2 inhibitor.

The risk factors that lead me to combine an NSAID with a PPI include:

Prior history of peptic ulcer disease, especially with past bleeding

from the stomach or upper portion of the intestine

High risk of internal bleeding because of other drugs (steroids,

warfarin) or medical issues (for example, chemotherapy lowering platelet

count)

Very advanced age

COX-2 inhibitors are a good idea in patients with brain tumors,

because NSAIDs might increase the risk of bleeding in and around these

tumors.

Everyone with a moderately increased risk of heart attack should be

taking aspirin.

So, for the vast majority of people who are worried about heart disease and

who have back and joint pains, my advice is to skip the COX-2s. There are

better, cheaper ways for you to go.

H. Lee, M.D., is the chief executive officer for Partners Community

HealthCare Inc. He is a professor of medicine at Harvard Medical School. He

is an internist and cardiologist at Brigham and Women's Hospital. Dr. Lee is

the chairman of the Cardiovascular Measurement Assessment Panel of the

National Committee for Quality Assurance.

http://www.intelihealth.com/IH/ihtIH/WSIHW000/35320/35324/403980.html?d=dmtHMSCo\

ntent

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org