This has been a painful year for
big drugs. One year ago, selective serotonin reuptake
inhibitors and cox-2 inhibitors were among the most
prescribed drugs. Though no data is available, it seems
likely that their popularity has waned following news
that certain SSRIs are linked to suicide and some cox-2
inhibitors to heart disease.
The cox-2 inhibitor's fall from
grace has been dramatically highlighted by a meta-analysis
of 19 randomized coxib trials involving 45,451 patients,
published online February 14 in the Archives of Internal
Medicine. The study, led by Dr Tai-Juan Aw of Alfred
Hospital in Melbourne, Australia, aims to quantify the
drugs' effects on blood pressure (BP) for the first
time.
Many of the analyzed trials noted
rises in hypertension, but deemed this acceptable, as
NSAIDs raise BP, and coxibs were meant to fill the role
of NSAIDs — the benefit being that coxibs don't
cause stomach bleeds. Other studies failed to note BP
at baseline, while some didn't insist on a washout period
to clear the subjects' systems of NSAIDs. The authors
acknowledge that a prospective double-blind trial would
be better, but such a trial is unlikely to ever happen
now. They argue that their results are "the best possible
summation of available information."
BP
RISING
Their results confirm why rofecoxib has been pulled
from shelves. Rofecoxib raised systolic pressure by
an average 5.66mmHg more than the placebo, while not
raising diastolic pressure at all. The resulting large
gap between systolic and diastolic pressure is known
to be a risk factor for cardiovascular disease.
Celecoxib, in contrast, continues
its successful escape from the cox-2 inhibitor train
wreck. It led to a weighted mean rise in systolic BP
of 2.6mmHg over placebo, while diastolic pressure was
1mmHg higher. This hypertensive effect is almost identical
to that of the NSAID naproxen. Moreover, there's no
alarming widening of the pulse pressure as is seen with
rofecoxib.
In conclusion, the authors call
cox-2 inhibitors a "welcome addition" to therapeutic
options in arthritis, but suggest that clinicians "weigh
the risks of improved gastrointestinal safety versus
potential hazards of developing BP... particularly in
the elderly population."
Arch Intern
Med published online Feb 14
|
