Tuesday, February 13, 2007

COX 2 and the Heart: The story continues

Cox2 inhibitors are drugs that relieve pain and inflammation. The problems with Cox2 was that many patients claim that Cox2 agent Vioxx caused their heart attacks. On review of some old literature, there was some justification for their claim, and MSD quickly withdrew Vioxx. In fact, when we looked into the issue, there was even some experimental evidence to support the claim that Cox2 inhibitors may in fact cause increase platelet aggregation. So the controversies go on and many law suits against MSD (Vioxx) are still pending in the US courts.

There are many Cox2 in the market, who are all watching to see how the courts decide. There is also new data coming in. The first issue of the American Journal of Cardiology for 2007 carried a meta-analysis of 41,000 patients who were either taking placebo, non-selective NSAIDs, or Celebrex (by Pfizer), and their association with cardiac events.

"White WB, West CR, Borer JS, et al. Risk of cardiovascular events in patients receiving celecoxib: a meta-analysis of randomized clinical trials. Am J Cardiol 2007; 99:91-98 ".

Dr White had actually presented this data at the 2006 Annual Scientific meeting of the American College of Cardiology. His team found no extra cardiac risk with the use of Celebrex, when compared to NSAIDs and placebo. We must not forget that this is a meta-analysis, and not a RCT, so undoubtedly, this will not be the last word on this subject.

Pfizer is so convinced that they are funding a large RCT on celebrex and comparing it with Ibuprofen and naproxsyn. The study is called PRECISION, and consist of 20,000 patients. I am sure that this will give us very valuable information on this subject. For the moment, I would advise that Cox2 inhibitors be used with great caution, or avoided all together in patients known to have heart disease or in patients with important coronary risk factors. NSAID, or NSAID with a small dose of Aspirin maybe a good alternative. Of course we are talking about chronic use of more then three months. I think that a one off or acute use, should not be an issue.

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