Pain Relievers: Questions & Answers
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Some studies have shown that Cox-2 inhibitors have been overprescribed. To whom should these drugs be prescribed?
In particular, a recent study published in the Archives of Internal Medicine showed that doctors were using Cox-2 drugs in a wide variety of patients instead of specifically selecting patients at risk for stomach bleeding as the ideal candidates. It was suggested that marketing and promotion of the drugs lead to their use in an unnecessarily large group of patients. Moreover, patients may have requested them because of perceived benefits.
Drug treatment is always based on a risk vs. benefit analysis. In clinical practice, Cox-2 inhibitors are considered after weighing the benefits vs. the risks. As more research clarifies the risks and the groups of patients who are more prone to these risks, it will become easier for patients and doctors to choose medications optimally.
Currently, Cox-2 drugs are most suited for patients who have a history of stomach or intestinal bleeding or who are at risk for bleeding. Persons who are taking the blood-thinning medication Coumadin cannot take traditional anti-inflammatory drugs because of high bleeding risks. When an anti-inflammatory drug is necessary, Cox-2 inhibitors are permissible for this group of patients.
The risks and benefits of taking a medication must be evaluated in an individualized fashion for each patient. The decision to take a medication requires knowledge of the severity of the condition treated, risks of alternatives, underlying medical conditions, past medication experiences, affordability of the drug, and the patient's age to adequately appreciate the risks.
If someone stops taking a Cox-2 drug, is the adverse risk of heart attack or stroke permanent?
No. There is no evidence of a sustained adverse effect. The risk would only be expected to be present while taking the drug, not after it has been discontinued.
It is interesting to note that the heart attack and stroke risk detected in the Vioxx study (which led its manufacturer to pull it from the market) did not present itself in study participants until the drug was taken for at least 18 months. There was no increased risk of heart attack or stroke detected in study participants who took Vioxx for less than 18 months. This suggests the possibility of some metabolism or enzyme change that takes time to occur in the body.