INFO - FAQs: COX-2 Pain Relievers ... What now?

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s Hopkins Arthritis Center

Spring 2005

Question:

Now that Bextra and Vioxx are no longer available,

what can my doctor substitute for pain control?

Answer:

Controversy surrounding the COX-2 inhibitors

including Vioxx®, Bextra®, and Celebrex® has been the

subject of much media coverage in the past months. This has

led to confusion in patients and physicians alike regarding

the use of the COX-2 inhibitors and even of the entire nonsteroidal

anti-inflammatory drug (NSAID) class.

Several clinical trials have noted an increase in

cardiovascular events. This concern and others are described

in detail on our Website (see page 5). The recent decision by

the FDA to remove both Vioxx® and Bextra® from the

market and to add a warning to the prescribing information

for Celebrex® has left many patients unsure of what

alternatives are available for pain control.

Your doctor may switch you to one of the non-selective

COX inhibitors (these are the NSAID drugs - such as

ibuprofen (Motrin, Advil), naproxen (Aleve), diclofenac

(Voltaren), and many more). Many of these drugs have been

used for decades and, importantly, have never been shown to

be inferior to the COX-2 inhibitors in ability to control pain.

The main side effects, which COX-2 drugs were developed

to prevent, are stomach discomfort and heart burn.

Gastrointestinal (GI) bleeding can occur as well, particularly

in older people and those taking higher doses of prednisone.

For these reasons, all NSAIDs should be taken with food.

Your doctor may choose to prescribe another medication

along with the NSAID to reduce the GI symptoms. One

option is a proton-pump inhibitor (PPI) (Prilosec®, Nexium®,

Prevacid®, and Aciphex®) which helps protect the stomach

lining from damage by decreasing acid production. NSAIDs

and PPIs can be safely taken together and PPIs have few

known side effects or drug interactions. Cytotec® may also

be prescribed with Arthrotec®. This medication also helps

protect the stomach lining, but does not reduce acid in the

stomach. The development of diarrhea and abdominal

cramping can limit its use in some people. It absolutely

cannot be taken in early pregnancy. Other options include H2

Blockers (Pepcid, Zantac, Axio). These reduce acid in the

stomach, but do not eliminate it.

Finally, your doctor may prescribe other non-NSAID

analgesics, such as acetaminophen (Tylenol) or tramadol

(Ultram, Ultracet). Narcotic analgesics should not be used to

treat chronic symptoms unless all other options are

ineffective. Some topically applied medications, such as

capsaicin cream or patches containing the local anesthetic

lidocaine, can provide relief for localized pain. Other

analgesic methods, such as acupuncture, can provide pain

relief in some people. It is important to remember that herbal

remedies can be effective in some people but, unlike the

NSAIDs and COX-2 inhibitors, most have received little or

no testing of safety or efficacy. These options may provide

pain relief, but unlike NSAIDs, do not reduce inflammation.

Decisions regarding the many options for pain control should

be actively discussed between you and your doctor. It is

important to let your doctor know about any over-thecounter

pain medications including supplements that

you take.

Written by Jon Giles, M.D.

http://www.hopkins-arthritis.som.jhmi.edu/corner/newsletters/spring2005.pdf

(PDF)

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Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

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