EDITORIAL - Patient benefit-risk in arthritis - a rheumatologist's perspective

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Rheumatology (Oxford). 2010 May; 49(suppl_2): ii11–ii17.

Published online 2010 April 7. doi: 10.1093/rheumatology/keq057.

PMCID: PMC2857791

Patient benefit–risk in arthritis—a rheumatologist’s perspective

Johannes W. J. Bijlsma1

1Department of Rheumatology and Clinical Immunology, University

Medical Center Utrecht, Utrecht, The Netherlands.

Corresponding author.

Correspondence to: Johannes W. J. Bijlsma, Department of Rheumatology

and Clinical Immunology, University Medical Center Utrecht, PO Box

85500, 3508 GA Utrecht, The Netherlands. E-mail:

j.w.j.bijlsma@... November 4, 2009; Revised January

29, 2010

Abstract

Introduction

There is a range of pharmacological options available to the

rheumatologist for treating arthritis. Non-selective NSAIDs or -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 -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 -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 -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 -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 -2 selective inhibitor or non-selective NSAID and

should choose appropriate agents for each individual patient.

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Read the full article here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2857791/

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