Cox-2 Inhibitors Off the Market

With Bextra now being taken off the market and most other NSAIDs(including naprosyn and ibuprofen) being slapped with strong label warnings, how have your departments dealt with the transition?

Responding to myself...


I for one, have been switching alot more patients over to tramadol(ultram) with acetaminophen. I've seen patients respond to it pretty well, with relatively little side effects(mild constipation, sedation). No more patient complaints than say the other NSAIDs anyway(GI upset, nausea)...

Plus you don't have to worry about damaging kidney function or causing gastric ulcers.

Sure there is that subset of people who are on SSRIs that they say you should be careful with in possibly causing a serotonin syndrome, but most of my attending have said that they have never seen this.

Of course, I'll still avoid using it in patients with a history of epilepsy or seizures, as the label says that tramadol could lower the seizure threshold. But if a person has a history of seizures, and if/when they do have one...how would you know that it wasn't related to the tramadol? You don't...But the malpractice lawyers would swear they do.

All and all, I think acetaminophen is a great drug. I should have bought stock in Tylenol...

Ultram is good. Have tried a little Mobic with varying success; though Mobic has problems too. Doing more modalities and joint protection principles with my RA and OA patients. What is old is new again.

The rheumatologist I've been working with gives everyone with OA this, saying it is the only disease-modifying drug available. He says there is an ongoing (NIH?) trial with preliminary results possibly demostrating a slowing or even halting of disease progression. Anyone have a link or know anything about this? Drusso, Stinky and others: do you use this alot in clinic?

MSK said:

The rheumatologist I've been working with gives everyone with OA this, saying it is the only disease-modifying drug available. He says there is an ongoing (NIH?) trial with preliminary results possibly demostrating a slowing or even halting of disease progression. Anyone have a link or know anything about this? Drusso, Stinky and others: do you use this alot in clinic?

Click to expand...

I have definetly seen a shift to more mobic and athrotec, as well as more tylenol and ultram, depending on the enviroment of the clinic. But, not to my suprise, less and less celebrex being re-writen for or given out.

As far as the glucosamine, when I was doiung rheum it was given out like water, along with calcium. There was no word of that study when I rotated through 4 months ago, and the 'ologist never refered to them as disease modifying agents. However, last month I rotated through a pain service in New York, and the doc I was with was not impressed with it, he chalked it up to placebo. In fact he was on CNN with a month ago on the Dr. Gupta medical show, discussing all the news surrounding the Cox's and NSAID, and he was asked specifically about the glucosamine supplements and he didn't think they were affective.

It would be intersting to see the NIH results. Even more interesting will be how the whole NSAIDs market changes.

Both arthrotec and ultracet are considered NONFORMULARY for many of our patients, so I end up writing separate prescriptions for tramadol and acetaminophen(ultracet) and diclofenac and misoprostol (arthrotec). Pain in the butt. Not to mention, more pills to take...

I've seen mixed results with glucosamine/chondroitin for knee OA, but mostly positive. But then again, I also usually use it in patients that are willing to wait for improvement. Those that want a quick fix where the "only thing that helps my pain is vicodin!" don't respond so well.

One of the good things about ultracet is the mere fact that it has "CET" in it. Patients somethings think "ooh...this is the good stuff...like percoSET and darvoCET". The smarter ones know better though. Especially when you don't write it on a special prescription pad.

MSK said:

The rheumatologist I've been working with gives everyone with OA this, saying it is the only disease-modifying drug available. He says there is an ongoing (NIH?) trial with preliminary results possibly demostrating a slowing or even halting of disease progression. Anyone have a link or know anything about this? Drusso, Stinky and others: do you use this alot in clinic?

Click to expand...

The glucosamine appears to be more important than the chondroitin. I've sprinkled it on people. Don't have a really clear sense that it works, but don't think that it harms either.

Will be interesting to see what happens with the 2nd Phase 3 trials by PAin Therapeutics for oxytrex, a combo of very low dose naltrexone with oxycodone. Supposedly alot less dependence, tolerance, constipation, nausea etc and equal or better pain relief (a public company so you know how that goes). The same company also has a 'less abusable' long acting oxycodone product in phase 3. Would love to have some better options for patients and some piece of mind while trying to help those in pain.

MSK

Thanks for the Glucosamine replies