Before the withdrawal of 2 COX-2 selective agents (COX-2s) from the market, many
rheumatoid arthritis patients were using these products regularly, with disease-modifying
antirheumatic agents. Clinical trials have shown benefit of COX-2s equivalent to nonselective nonsteroidal anti-inflammatory drugs (NS-
NSAIDs) in
rheumatoid arthritis. Better gastrointestinal (GI) safety has been demonstrated with COX-2s; numerical but not statistical benefit with concomitant use of cardiovascular (CV) doses of
aspirin. COX-2 benefit may extend to lower GI blood loss against which
proton pump inhibitors are not protective. COX-2s are associated with
hypertension and
edema of similar magnitude to NS-
NSAIDs in predisposed individuals. Epidemiologic studies and clinical trials have confirmed the association of serious thromboembolic (CV) events and
congestive heart failure with
rofecoxib>25 mg daily,
celecoxib, and NS-
NSAIDs, although there is a paucity of long-term data. Important questions remain regarding relative GI and CV risks: is concomitant
aspirin protective when coadministered with COX-2s? Does this abrogate their GI benefit? As identified many years ago with NS-
NSAIDs, patients may respond to one and not another; COX-2s should be considered individually and not as a single "class." Patients deserve the opportunity to make a choice about the perceived benefit/risk assessment when using these
therapies, with the collaboration of their physician.