The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.
Letter to the Editor
Editor, – Regarding the article 'The vascular effects of COX-2 selective inhibitors' (Aust Prescr 2004;27:142-5), I agree that 'Low-dose aspirin or other anti-thrombotic treatment should be continued in patients receiving selective COX-2 inhibitors who are at risk of thrombosis'. However, one must ask why would we choose selective COX-2 inhibitors instead of conventional non-steroidal anti-inflammatory drugs (NSAIDs) for patients taking anti-platelet therapy?
In the CLASS study, patients who took celecoxib and aspirin (approximately 20% of nearly 8000 patients) had the same annualised incidence of symptomatic ulcers and upper gastrointestinal ulcer complications as patients taking aspirin with an NSAID (either ibuprofen 800 mg tds or diclofenac 75 mg bd).1 The literature suggests that the principal 'advantage' of upper gastrointestinal safety is lost when a COX-2 inhibitor is co-prescribed with aspirin.
Published reports also show that patients taking COX-2 inhibitors appear to have only slightly fewer upper gastrointestinal symptoms (such as dyspepsia) than patients treated with conventional NSAIDs.2
The COX-2 inhibitors have a substantial cost premium, but marginal safety advantages in some selected patients. With reference to your recent editorial 'Expensive new drugs - do we really need them?' (Aust Prescr 2004;27:136-7), the data would suggest that the COX-2 inhibitors are another example of expensive new drugs with an unclear cost-benefit value for the Pharmaceutical Benefits Scheme.
Royal Brisbane Hospital & Royal Women's Hospital and Health Service Districts
- Silverstein FE, Faich G, Goldstein JL, Simon LS, Pincus T, Whelton A, et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis: the CLASS study: a randomised controlled trial. Celecoxib Long-term Arthritis Safety Study. JAMA 2000;284:1247-55..
- Langman MJ, Jensen DM, Watson DJ, Harper SE, Zhao PL, Quan H, et al. Adverse upper gastrointestinal effects of rofecoxib compared with NSAIDs. JAMA 1999;282:1929-33.
- Schnitzer TJ, Burmester GR, Mysler E, Hochberg MC, Doherty M, Ehrsam E, et al. Comparison of lumiracoxib with naproxen and ibuprofen in the Therapeutic Arthritis Research and Gastrointestinal Event Trial (TARGET), reduction in ulcer complications: randomised controlled trial. Lancet 2004;364:665-74.
- Chan FK, Graham DY. Review article: prevention of non-steroidal anti-inflammatory drug gastrointestinal complications - review and recommendations based on risk assessment. Aliment Pharmacol Ther 2004;19:1051-61.
- Bensen WG, Zhao SZ, Burke TA, Zabinski RA, Makuch RW, Maurath CJ, et al. Upper gastrointestinal tolerability of celecoxib, a specific COX-2 inhibitor, compared to naproxen and placebo. J Rheumatol 2000;27:1876-83.