COX-2 and proton pump inhibitor coprescribing is "justified"

By Richard Woodman

LONDON (Reuters Health) – The new cyclooxygenase 2 (COX-2) inhibitors, commonly prescribed for arthritis pain, can cause gastric problems, which justifies the coprescription of proton pump inhibitors, a British specialist said on Wednesday.

One argument put forward by companies marketing COX-2 inhibitors is that they are far safer than traditional NSAIDs and that major savings can therefore be made by reducing the use of proton pump inhibitors, such as omeprazole.

But Professor David Blake at the Royal National Hospital for Rheumatic Diseases in Bath, southwest England, said: "It is not true to say that the COX-2 inhibitors are without gastric problems. Therefore most sensible doctors carry on with the proton pump inhibitor cover for at least a while."

He added in an interview with Reuters Health that the recent decision of France's Caisse nationale d'assurance maladie to investigate levels of coprescribing of the two drugs because of cost concerns showed that French doctors were being cautious. "One can congratulate them for this."

Professor Blake, chair of the Royal College of Physicians' specialist rheumatology committee, said that the general advice given in Britain is that there is no need to coprescribe the two drugs. "Nevertheless I can assure you that plenty of doctors do, and I would be one of them."

He explained that doctors did not want to withdraw proton pump inhibitors until everyone was confident that the COX-2 was going to be a permanent drug, was having the desired effect, and was not causing any gastric problems.

He noted: "The incidence of gastric problems is significantly reduced with COX-2 inhibitors compared with traditional NSAIDs, but [GI problems] are not absolutely reduced."

Deciding how long to coprescribe is a dilemma. "I have no doubt someone will produce guidance, but I would hate to be the person who had to produce it and would be amazed at the person who could say it with confidence," Prof. Blake said.

The relationship between symptoms, ulcers and bleeds was still unclear, the professor added. While the argument against coprescribing might be convincing when looked at from the point of view of 1000 patients, "we treat individual patients," he pointed out.

Pharmacia, which markets the COX 2 inhibitor Celebrex, also supported coprescribing it with proton pump inhibitors, but only for a limited period to allow time for existing gastric erosion or ulcer to heal.

"That period would vary according to clinical discretion but could be anything from 6 to 8 weeks," said Dr. Brian Muller, senior medical adviser at the firm's UK offices. The period would depend on factors including Helicobacter pylori infection, alcohol consumption and smoking.

"There is no reason why a clinician would coprescribe a [COX-2 inhibitor] together with a proton pump inhibitor for gastric protection in the absence of a previous history of gastric problems," Dr. Muller said

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