When should COX-2 selective NSAIDs be used for osteoarthritis and rheumatoid arthritis?

TABLE 1
Prediction of serious gastrointestinal bleeding

Recommendations from others

The American Pain Society recommends that for patients with osteoarthritis, acetaminophen is the drug of choice for mild pain.¹³ For moderate to severe pain and or inflammation, a COX-2 selective NSAID is the first choice, unless the patient is at significant risk for hypertension or renal disorder. For patients with active rheumatoid arthritis and moderate to severe pain with or without inflammation, a COX-2 selective NSAID should be used concomitantly with a disease-modifying antirheumatic drug (DMARD), unless contraindicated by existing uncontrolled hypertension and renal disease. It further recommends that for a person who is at risk for a cardiovascular event, an aspirin (75–160 mg/d), should be given along with a COX-2 selective NSAID.

The American College of Rheumatology recommends that a COX-2 selective NSAID should be considered for a person with osteoarthritis and pain not relieved by an adequate dose of acetaminophen (not to exceed 4 g/d).^14,15 The COX-2 selective NSAID is particularly advantageous for those who have higher risk factors for adverse GI events (TABLE 2). For a person with rheumatoid arthritis, in addition to DMARDs, NSAIDs (salicylates, nonselective NSAID, or COX-2 selective NSAID) should be used to reduce joint pain and swelling and improve joint function. Patients with additional risks for cardiovascular events should be cautioned about use of a COX-2 selective NSAID.

A recent AHRQ report on managing osteoarthritis underscores the importance of physician-patient partnership and patient’s self management of osteoarthritis, and recommends acetaminophen (up to 4 g/day) as the drug of choice.¹⁶ It further cautions the injudicious use of NSAIDs because of its greater GI toxicity when compared with acetaminophen, and its higher medical costs.

TABLE 2
Risk factors for upper gastrointestinal adverse events