COX2 Selective NSAID

Aka: COX2 Selective NSAID, COX2 Inhibitor, COX-2 Inhibitor

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II. Class

  1. NSAID in the COX2 selective class

III. Agents

  1. COX-2 Inhibitors
    1. Celecoxib (Celebrex)
    2. Rofecoxib (Vioxx) - withdrawn from U.S. market in 2004
    3. Valdecoxib (Bextra) - withdrawn from U.S. market in 2005
  2. NSAIDs which favor COX-2 (alternatives to COX-2)
    1. Etodolac (Lodine)
    2. Nabumetone (Relafen)
    3. Meloxicam (Mobic)
      1. However, higher risk of NSAID Gastrointestinal Adverse Effects

IV. Advantages

  1. Less gastrointestinal adverse effects than other NSAIDs
    1. See NSAID Gastrointestinal Adverse Effects
    2. Cost may not outweigh benefits
      1. Number Needed to Treat to prevent 1 GI Bleed: 200
        1. (2000) N Engl J Med 343:1520-8 [PubMed]
      2. Studies showing decreased GI Bleeds were flawed
        1. Compared Celebrex to high risk NSAID (Diclofenac)
        2. Confidence Interval overlaps 1.0
        3. (2000) JAMA 284:1247-55 [PubMed]
  2. No inhibition of Platelet aggregation
    1. No increase in Bleeding Time
    2. May have pro-thrombotic effect

V. Adverse Effects

  1. Nonfatal Acute MI risk increased over NSAIDs
    1. Vioxx voluntarily withdrawn from market October 2004
    2. Celebrex however appears safer than Ibuprofen in terms of Cardiovascular Risk
      1. Ruschitzka (2017) Eur Heart J +PMID:29020251 [PubMed]
    3. Avoid if known vascular disease
    4. Avoid if significant Cardiac Risk Factors
  2. Adverse renal effects may occur
    1. Hypertension (1%)
    2. Peripheral Edema (2-4%)
  3. References
    1. Fitzgerald (2001) N Engl J Med 345:433-42 [PubMed]

VI. Efficacy

  1. Similar effect to moderate dose NSAIDs
    1. NaproxenSodium 550 mg
    2. Ibuprofen 400 mg

VII. Indications

  1. Osteoarthritis
  2. Rheumatoid Arthritis
  3. Acute pain
  4. Familial adenoma polyposis
  5. Arthritic pain relief in NSAID intolerant
    1. Bleeding risk
    2. Peptic Ulcer Disease
    3. Concomitant gastrointestinal symptoms
    4. Age over 65 years
    5. Concurrent medication predisposing to Gastritis
      1. Corticosteroids
      2. Coumadin (Off-label use of COX2 Inhibitor)

VIII. Monitoring

  1. ProTime if on Coumadin
    1. Check ProTime weekly for first 4 weeks
  2. Consider checking labs at 6 months
    1. Complete Blood Count
    2. Aspartate Aminotransferase (AST, SGOT)

IX. References

  1. (1999) Med Lett Drugs Ther 41(1045): 11-14 [PubMed]
  2. (2000) Med Lett Drugs Ther 42(1085): 73-78 [PubMed]

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