title: Patient benefit-risk in arthritis--a rheumatologist's perspective.
abstract: There is a range of pharmacological options available to the rheumatologist for treating arthritis. Non-selective NSAIDs or Cox-2 selective inhibitors are widely prescribed to reduce inflammation and alleviate pain; however, they must be used with caution in individuals with an increased cardiovascular, renal or gastrointestinal (GI) risk. The potential cardiovascular risks of Cox-2 selective inhibitors came to light over a decade ago. The conflicting nature of the study data reflects some context dependency, but the evidence shows a varying degree of cardiovascular risk with both Cox-2 selective inhibitors and non-selective NSAIDs. This risk appears to be dose dependent, which may have important ramifications for arthritis patients who require long-term treatment with high doses of anti-inflammatory drugs. The renal effects of non-selective NSAIDs have been well characterized. An increased risk of adverse renal events was found with rofecoxib but not celecoxib, suggesting that this is not a class effect of Cox-2 selective inhibitors. Upper GI effects of non-selective NSAID treatment, ranging from abdominal pain to ulceration and bleeding are extensively documented. Concomitant prescription of a proton pump inhibitor can help in the upper GI tract, but probably not in the lower. Evidence suggests that Cox-2 selective inhibitors are better tolerated in the entire GI tract. More evidence is required, and a composite end-point is being evaluated. Appropriate treatment strategies are needed depending on the level of upper and lower GI risk. Rheumatologists must be vigilant in assessing benefit-risk when prescribing a Cox-2 selective inhibitor or non-selective NSAID and should choose appropriate agents for each individual patient.
authors.affiliation: Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands. j.w.j.bijlsma@umcutrecht.nl
authors.forename: Johannes W J
authors.initials: JW
authors.lastname: Bijlsma
mesh_terms: D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects* / Q000627:therapeutic use*; D001168:Arthritis / Q000188:drug therapy*; D002318:Cardiovascular Diseases / Q000139:chemically induced; D052246:Cyclooxygenase 2 Inhibitors / Q000009:adverse effects / Q000627:therapeutic use; D005767:Gastrointestinal Diseases / Q000139:chemically induced; D006801:Humans; D007674:Kidney Diseases / Q000139:chemically induced; D018570:Risk Assessment / Q000379:methods
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D052246:Cyclooxygenase 2 Inhibitors
references.citation: Ann Intern Med. 1995 Aug 15;123(4):241-9
references.pmid: 7611589
references.citation: Arch Intern Med. 2000 Jul 24;160(14):2093-9
references.pmid: 10904451
references.citation: Scand J Rheumatol. 2001;30(1):11-8
references.pmid: 11252686
references.citation: Clin Gastroenterol Hepatol. 2007 Jul;5(7):818-28, 828.e1-5; quiz 768
references.pmid: 17556027
references.citation: Am J Med. 2006 Mar;119(3):255-66
references.pmid: 16490472
references.citation: Digestion. 2006;73 Suppl 1:136-50
references.pmid: 16498262
references.citation: JAMA. 2000 Sep 13;284(10):1247-55
references.pmid: 10979111
references.citation: Arthritis Rheum. 2000 Sep;43(9):1905-15
references.pmid: 11014340
references.citation: JAMA. 2006 Oct 4;296(13):1619-32
references.pmid: 16968832
references.citation: Ann Rheum Dis. 2009 Mar;68(3):367-72
references.pmid: 18408253
references.citation: N Engl J Med. 2002 Dec 26;347(26):2104-10
references.pmid: 12501222
references.citation: Ann Med. 2006;38(6):415-28
references.pmid: 17008305
references.citation: BMJ. 2006 Jun 3;332(7553):1302-8
references.pmid: 16740558
references.citation: Am J Med. 1999 May 31;106(5B):13S-24S
references.pmid: 10390124
references.citation: Ann Rheum Dis. 2007 Jan;66(1):34-45
references.pmid: 16396980
references.citation: Ann Rheum Dis. 2004 Aug;63(8):931-9
references.pmid: 15082468
references.citation: Gastroenterology. 2002 Oct;123(4):1006-12
references.pmid: 12360461
references.citation: Arch Intern Med. 2009 Jan 26;169(2):141-9
references.pmid: 19171810
references.citation: Ann Intern Med. 2002 Jan 15;136(2):161-72
references.pmid: 11790072
references.citation: Ann Rheum Dis. 2003 Dec;62(12):1145-55
references.pmid: 14644851
references.citation: J Rheumatol Suppl. 1991 Mar;28:11-4
references.pmid: 1903808
references.citation: JAMA. 2006 Oct 4;296(13):1633-44
references.pmid: 16968831
references.citation: Arthritis Rheum. 2002 Feb;46(2):328-46
references.pmid: 11840435
references.citation: Eur Heart J. 2006 Jul;27(14):1657-63
references.pmid: 16731535
references.citation: Am J Gastroenterol. 2009 Jul;104(7):1633-41
references.pmid: 19574968
references.citation: Gastroenterology. 2003 Feb;124(2):288-92
references.pmid: 12557133
references.citation: N Engl J Med. 2000 Nov 23;343(21):1520-8, 2 p following 1528
references.pmid: 11087881
references.citation: N Engl J Med. 2005 Mar 17;352(11):1071-80
references.pmid: 15713944
references.citation: BMJ. 1995 Apr 1;310(6983):827-30
references.pmid: 7711618
references.citation: Aliment Pharmacol Ther. 2006 Sep 1;24(5):751-67
references.pmid: 16918879
references.citation: Rheumatology (Oxford). 2006 Sep;45(9):1167-9
references.pmid: 16844700
references.citation: N Engl J Med. 2005 Mar 17;352(11):1092-102
references.pmid: 15713943
references.citation: Lancet. 2007 Feb 10;369(9560):465-73
references.pmid: 17292766
references.citation: Lancet. 2007 May 12;369(9573):1621-6
references.pmid: 17499604
references.citation: J Rheumatol Suppl. 1998 May;51:8-16
references.pmid: 9596549