Endoscopic studies have shown that cyclo-oxygenase-1 sparing non steroidal anti-inflammatory drugs (
NSAIDs) of the
coxib family did not produce more
gastroduodenal ulcers than placebo in patients who were free of
ulcer at baseline. However, the clinical relevance of these data is disputable. Only
celecoxib and
rofecoxib have been subject to large scale gastrointestinal outcome studies. Both have been shown to reduce the risk of symptomatic
ulcers and
ulcer complications (perforation,
gastric outlet obstruction,
bleeding) by about 50% compared to classical
NSAIDs used at their maximum therapeutic doses. However,
coxibs appear to retain some residual risk, especially in patients at high risk of developing serious gastrointestinal adverse events. This is the case in patients requiring low dose
aspirin for cardiovascular purposes. Whether
coxibs are still less toxic to the gastroduodenal tract that non-selective
NSAIDs in these patients is controversial. Although
coxibs have a superior upper gastrointestinal tolerability relative to traditional
NSAIDs,
dyspepsia,
abdominal pain and
nausea remain the major factor limiting their use.