The VIGOR trial was the first trial to suggest a higher incidence of adverse CV outcomes with COX-2 selective inhibitors
compared with tNSAIDs.
From a practical standpoint, further understanding on how COX-2 impacts cardiomyocytes apoptosis may have profound clinical implications in the light of the significant role of apoptosis in ischemic heart disease and the widespread use of COX-2 selective inhibitors
The incidences of upper gastrointestinal clinical events have been shown to be significantly less with COX-2 selective inhibitors than traditional NSAIDs in randomised gastrointestinal outcomes trials of 12 weeks - 12 months' duration.
COX-2 selective inhibitors have also been reported to induce less dyspepsia than traditional NSAIDs.
Patients with moderate-to-severe pain due to OA should be treated initially with an intra-articular glucocorticoid or an oral NSAID according to the ACR, (25) while the American Pain Society recommends a COX-2 selective inhibitor.
The ACR recommends treatment be initiated with patient education and physical therapy, a DMARD or DMARDs, and possibly a corticosteroid and/or an NSAID or COX-2 selective inhibitor.
Despite the gastrointestinal tolerance of cox-2 selective inhibitors
, it is established that renal and cardiovascular effects of cox -2 selective inhibitors are similar to those of non-selective NSAIDs.
From a clinical perspective, the effectiveness of COX-2 selective inhibitors, in terms of antiinflammatory activity and pain relief, are comparable to those effects of NS-NSAIDs, at least in the studies that have been used as pivotal for approval.
66) Preliminary evidence also suggests overall reduced GI complications with the COX-2 selective inhibitors compared with NS-NSAIDs, even with concomitant use of proton pump inhibitors.
Although celecoxib is an effective NSAID, rofecoxib and lumericoxib are the only COX-2 selective inhibitors
that definitively reduce gastrointestinal (GI) ulcerations/complications compared with nonselective NSAID therapy.
DISCUSSION: Until recently the new COX-2 selective inhibitors
have been increasingly used.
At low doses, some COX-2 selective inhibitors
may have no greater cardiovascular risk than other NSAIDs.
Before withdrawal of Rofecoxib, the prescriptions of COX-2 selective inhibitors
had accounted for 37% of the total NSAID prescriptions dispensed.
For patients at high risk, COX-2 selective inhibitors
are reasonable second-line agents, since they pose a lower risk of NSAID-associated gastrointestinal complications with long-term use.