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Update on the COX-2 Medications

By Ed Nguyen, M.D., Attending Physician at 75th St. & 126th St. Medical, Ocean Pines Medical & Doctors Weight Control & Wellness centers, Ocean City, MD.

As the debate over the efficacy and safety of COX-2 drugs continues, hearings have recently concluded at a Food and Drug Administration advisory panel assessing the continued usage of these drugs. At the center of the controversy is Vioxx (rofecoxib), produced by Merck, a COX-2 drug pulled from the market late last year. The medication arose concerns after a colon-cancer prevention study suggested a definite correlation between high-dose Vioxx usage and cardiac and stroke complications.

The good news for former Vioxx users is that the FDA panel has deemed Vioxx to be safe enough to be allowed back onto the U.S. market. Possible recommendations, however, might limit the use of this medication only to patients with a low risk of cardiac disease, might suggest a dosage reduction, or might require updated drug label warnings about possible hazards. Currently, the other COX-2 medications on the U.S. market are Celebrex (celecoxib) and Bextra (valdecoxib), both produced by Pfizer, though neither are not without controversy, too. Bextra is contraindicated in cardiac-bypass patients due to increased cardiac risk. While short-term and low-dose usage of either Celebrex or Bextra appears to pose little risk to regular patients, the long-term evidence is conflicting or incomplete, and opinions differ widely within the medical community.

The COX-2 drugs relieve the pain of arthritis by blocking an enzyme involved in the process of tissue inflammation. These drugs first arrived on the marketplace approximately six years ago as alternatives to the nonsteroidal anti-inflammatory drugs (NSAIDs). Vioxx in particular boasted a protective benefit over the gastrointestinal side effects common with NSAIDs.

Naturally, many patients may still express some concerns over the COX-2 medications as treatment for their arthritic pain. In such cases, low-dose aspirin or one of the NSAIDs still generally provides good degree of pain relief. The NSAIDs with the best safety profile include lodine (etodalac) at 400mg twice or three times a day and Relafen (nabumetone) at 500-750mg two or three times a day. Another promising NSAID is Mobic (meloxicam), although long-term studies on this medication at still ongoing.

Patients who are unable to take NSAIDS due to ulcers or other gastrointestinal complaints can certainly try Tylenol (acetaminophen), which is safe and efficacious at 1000mg three times a day. Glucosamine and chondroitin sulfate supplements are likewise perfectly safe, as both components are naturally-occurring in the body. Glucosamine promotes formation and repair of the cartilage in joints, while chondroitin helps to maintain the elasticity of cartilage. Patients can also try flaxseed or celery seed extract, both natural compounds. Flaxseed oil is high in LA, an essential fatty acid that is beneficial for heart disease and arthritis.

Above all, don't forget that exercise is crucial for people with arthritis. A sedentary lifestyle can actually make the pain worse. Even low-impact exercise (stretching, walking, swimming, for instance) is better than no exercise at all.

In the meantime, the continuing debate over the benefits versus risks of the COX-2 drugs is unlikely to be resolved anytime soon. Just keep in mind that there are other alternatives to fighting arthritic pain. Patients should consult with their personal physicians to determine what form of pain management is best suited for them.

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