Pooled analysis of GI tolerability of 21 randomized controlled trials of celecoxib and nonselective NSAIDs

ABSTRACT

Objective: To compare the gastrointestinal (GI) tolerability of celecoxib and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) at approved doses in patients with common musculoskeletal conditions.

Research design and methods: This was a retrospective, pooled analysis of studies selected from the Pfizer Corporate Clinical Trials Registry. Study selection criteria were: (1) Data available as of October 31, 2004; (2) Randomized, parallel-group study design and planned treatment duration of ≥?2 weeks; (3) At least one nonselective NSAID (naproxen, ibuprofen, or diclofenac) as a comparator; (4) At least one arm with 200?mg or 400?mg celecoxib per day; (5) Patients with osteoarthritis (OA), adult rheumatoid arthritis (RA), or ankylosing spondylitis (AS).

Data were pooled by treatment and by subject from the safety analysis population of each included study. Joint primary end points were the combined incidence of tolerability-related GI adverse events (AEs) (abdominal pain, dyspepsia, nausea, diarrhea, and flatulence), and time to study discontinuation due to any GI?AE.

Results: In all, 21 studies met the selection criteria. Across the safety analysis populations of the included studies, 7797 patients received celecoxib total daily dose 200?mg/day, 6653 received celecoxib total daily dose 400?mg/day, 2953 received naproxen, 499 received ibuprofen, and 5643 received diclofenac. Tolerability-related GI AEs were reported by significantly fewer celecoxib-treated patients (16.0%) than by those treated with naproxen (24.3%), ibuprofen (24.2%), or diclofenac (19.9%) (p?<?0.0001 vs. each comparator). Time to study discontinuation due to any GI?AE was significantly longer for celecoxib than for naproxen (p?<?0.0001), ibuprofen (p?=?0.002), or diclofenac (p?=?0.048). In the RA subpopulation (n?=?2857), there was no significant difference between the celecoxib and naproxen or ibuprofen groups in incidence of tolerability-related GI AEs and GI AEs.

Limitations: The limitations are inherent to the retrospective analysis design.

Conclusions: In this pooled analysis of celecoxib at approved doses in OA, RA, and AS, fewer celecoxib-treated patients in the overall population had tolerability-related GI AEs than patients treated with naproxen, ibuprofen, or diclofenac. In addition, celecoxib-treated patients had a significantly longer time to study discontinuation due to GI AEs.     

Pharmacist intervention reduces gastropathy risk in patients using NSAIDs

Objective To establish a detection and intervention strategy in order to reduce the number of non-steroidal anti-inflammatory drug (NSAIDs) users at risk of gastropathy from receiving either inadequate or no gastroprotection. Setting Community Pharmacies in Valencia, Spain. Method Prospective longitudinal intervention study without control group carried out by 79 Community Pharmacies. Patients over 18 who asked for any systemic NSAID were interviewed according to standard procedure. Pharmacist intervention was carried out when a patient at risk of serious NSAID-induced gastrointestinal complications due to inadequate or no gastric protection was identified. The doctor responsible was informed in order to then be able to assess the need to prescribe gastroprotection or change it if inadequate. In the case of over-the-counter (OTC) drugs, pharmacist intervention mainly involved replacing NSAIDs for safer medications. Main outcome measure Firstly, the number of patients who had no prescribed gastroprotection or inadequate gastroprotection was determined. Pharmacist intervention then brought about changes in pharmacotherapy in this situation. Results Of the 6,965 patients who asked for NSAIDs during the study period, 3,054 (43.9%) presented NSAID gastropathy risk factors. 35.6% of the latter (1,089) were not prescribed gastroprotection or were prescribed inadequate gastroprotection. Pharmacist intervention was carried out in 1,075 of these cases. On 391 occasions such risk situations were reported to doctors, who accepted pharmacist intervention on 309 occasions (79.0%) and then either prescribed gastroprotection (77% of cases); changed it (13.9%); withdrew the NSAID (5.8%) or substituted it (3.2%). 235 Pharmacist interventions took place when dispensing OTC NSAIDs. Conclusion Our strategy allowed us to identify a large number of patients who asked for NSAIDs in Community Pharmacies and who were at risk of NSAID gastropathy, as they received either inadequate gastroprotection or no gastroprotection whatsoever. Moreover, the pharmacist intervention carried out has reduced the number of these risk situations.     

Strategy for development of NSAIDs with lower risk for side effects

Nonsteroidal antiinflammatory drugs (NSAIDs) are one of the most frequently used classes of medicines worldwide. The major clinical problem encountered with the use of NSAIDs is gastrointestinal complications. In the USA, about 16,500 people per year die as a result of NSAID-associated gastrointestinal complications. COX-2-specific NSAIDs have been developed as safer for the gastrointestinal tract, although the risk of cardiovascular thrombotic disease has recently been noted with the use of COX-2-specific NSAIDs. To find the strategy for the development of gastrointestinally safe NSAIDs other than COX-2-specific NSAIDs, we examined the molecular mechanism for NSAID-induced gastric ulcer formation. We found that NSAIDs induce gastric mucosal cell death in a manner independent of COX inhibition and that this cytotoxic effect is due to their membrane permeabilization activity, which is not required for the antiinflammatory activity of NSAIDs. Furthermore, we showed that in addition to COX inhibition by NSAIDs, direct cytotoxicity of NSAIDs is required for NSAID-induced gastric ulcer formation. These results suggest that NSAIDs that have neither membrane permeabilization activity nor COX-2 specificity would be safe for both the gastrointestinal tract and cardiovascular system and we are now chemically synthesizing such NSAIDs.     

NSAIDs and chemoprevention

Several epidemiological, clinical and experimental studies established nonsteroidal anti-inflammatory drugs (NSAIDs) as promising cancer chemopreventive agents. Long-term use of aspirin and other NSAIDs has been shown to reduce the risk of cancer of the colon and other gastrointestinal organs as well as of cancer of the breast, prostate, lung, and skin. Understanding the action of NSAIDs provides substantial insights into the mechanisms by which these unique agents regulate tumor cell growth and enable better strategies for prevention and treatment. NSAIDs restore normal apoptosis and reduce cell proliferation in human adenomatous colorectal polyps, experimental colonic tumors, and in various cancer cell lines that have lost critical genes required for normal function. NSAIDs, particularly selective cyclooxygenase-2 (COX-2) inhibitors such as celecoxib, have been shown to inhibit angiogenesis in cell culture and in rodent models of angiogenesis. Exploration of the multistep process of carcinogenesis has provided substantial insights into the mechanisms by which NSAIDs modulate these events. However, unresolved questions with regard to safety, efficacy, optimal treatment regimen, and mechanism of action currently limit the clinical application of NSAIDs to the prevention of polyposis in FAP patients. Moreover, the development of safe and effective NSAIDs for chemoprevention is complicated by the potential that rare, serious toxicity may offset the benefit of treatment with these drugs given to healthy individuals who have a low risk of developing the disease. Growing knowledge in this area has brought about innovative approaches using combine actions of NSAIDs with other agents that have different modes of action. It has also led to the development of nitric oxide-releasing NSAIDs, that induce tumor cell apoptosis and compensate for COX function, as a means of increasing efficacy and minimizing toxicity. There is growing optimism for the view that full exploration of the role of NSAIDs in the prevention and treatment of epithelial cancers will serve towards reducing of mortality and morbidity from various cancers.     

Exposure to phototoxic NSAIDs and quinolones is associated with an increased risk of melanoma

Purpose

Ultraviolet radiation exposure is the most important exogenous risk factor for cutaneous malignancies. It is possible that phototoxic drugs promote the development of cutaneous melanoma (CM) by intensifying the effect of ultraviolet light on the skin. We investigated the association between the use of common systemic phototoxic drugs and development of CM.

Methods

This study was a case–control study in a Dutch population-based cohort. The drug dispensing data was obtained from PHARMO, a Dutch drug dispensing and hospital admissions registry, and linked to PALGA, the nationwide pathology network of the Netherlands. The cases were patients diagnosed with pathologically confirmed primary CM between 1991 and 2004. Controls were sampled from the PHARMO population. Exposure to systemic phototoxic drugs was measured and included antimicrobial agents, diuretics, antipsychotic drugs, antidiabetic drugs, cardiac drugs, antimalarials and nonsteroidal anti-inflammatory drugs (NSAIDs). A multivariate conditional logistic regression analysis was performed to study the association between exposure to phototoxic drugs and CM.

Results

The study population included 1,318 cases and 6,786 controls. Any phototoxic drug during the study period was dispensed for 46 % of the cases and 43 % of the controls (p?=?0.012). The use of quinolones [odds ratio (OR) 1.33, 95 % confidence interval (CI) 1.01–1.76] and propionic acid derivative NSAIDs (OR 1.33, 95 % CI 1.14–1.54) had a positive association with CM.

Conclusions

Our study shows that the use of phototoxic drugs is associated with an increased risk of developing CM. Even a short-term use of phototoxic quinolones and propionic acid derivative NSAIDs may increase the risk for CM. Patient education to promote sun-protective behaviour is essential to avoid immediate adverse effects and possible long-term effects of phototoxic drugs.