Heart Experts Issue Guidelines on Use of Celebrex

Cox-2 painkiller should be last resort because of cardiovascular risk, American Heart Association says

MONDAY, Feb. 26, 2007 (HealthDay News) -- The American Heart Association is weighing in on the potential heart dangers of controversial cox-2 nonsteroidal anti-inflammatory drug (NSAID) painkillers such as Celebrex.

In a statement published Monday in Circulation, the association says these painkillers -- which include two other drugs, Vioxx and Bextra, now withdrawn from the market -- do increase the risk of heart attack and stroke, and doctors need to change the way they prescribe these pain relievers to people with, or at risk for, heart disease. Cox-2 pain relievers are so named because they specifically target the cox-2 enzyme.

However, other, less targeted or "selective" non-cox-2 NSAIDs may also increase the risk, the AHA said.

"We believe that some physicians have been prescribing the new cox-2 inhibitors as the first line of treatment. We are turning that around and saying that, for chronic pain in patients with known heart disease or who are at risk for heart disease, these drugs should be the last line of treatment," statement author Dr. Elliott M. Antman, a professor of medicine at Harvard Medical School and Brigham and Women's Hospital, said in a prepared statement.

"We advise physicians to start with non-pharmacologic treatments such as physical therapy and exercise, weight loss to reduce stress in joints, and heat or cold therapy. If the non-pharmacologic approach does not provide enough pain relief or control of symptoms, we recommend a stepped-care approach when it comes to prescribing drugs," Antman said.

This approach takes into account the notion that a variety of NSAIDs affect cox-2 in more or less selective ways.

"Take into account the patient's health history and consider acetaminophen, aspirin and even short-term use of narcotic analgesics as the first step," the expert said. "If further relief is needed, physicians should suggest the least selective cox-2 inhibitors first, moving progressively toward more selective cox-2 inhibitors, which are at the bottom of the list, only if needed. All drugs should be used at the lowest dose necessary to control symptoms and prescribed for the shortest time possible."

A number of studies have concluded that the use of cox-2 selective NSAIDs (designed to reduce gastrointestinal side effects caused by traditional NSAIDs) increase the likelihood of cardiovascular disease complications in people with, or at risk for, heart disease, Antman said.

A meta-analysis found that cox-2 selective NSAIDs were associated with an 86 percent increased risk of heart attack, said the scientific statement, which also noted that two non-cox-2 NSAID drugs -- diclofenac and ibuprofen -- may also increase the risk of heart problems.

In recent years, the U.S. Food and Drug Administration has added warning statements to NSAIDs (with the exception of aspirin) about an increased risk of cardiovascular events when taking these drugs, the scientific statement noted.

More information

MedlinePlus has more about NSAIDs.

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