Celebrex 400 mg BID
Started by Sparda29
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That's stupid...why would you put someone on plavix for no apparent reason. He would laugh at you and tell you to go back to school.
I don't understand this. Can you explain what you mean?
the idea is that COX-2 is naturally cardioprotective and that by blocking COX-2, the PGI2/TXA2 ratio is shifted toward TXA2, favoring vasoconstriction and platelet aggregation. it's something that's been studied in petri dishes but i'm not sure any doctor would prescribe prophylactic plavix based on that evidence
http://www.jimmunol.org/content/167/5/2831.long
http://www.jimmunol.org/content/167/5/2831.long
You say "studied in petri dishes" like it didn't get Vioxx and Bextra yanked off the market. If you have Arachadonic acid in your body, it will be made into something. Blocking COX-2 means more goes through the COX-1 pathway. If that's not what someone is concerned about with high doses of Celebrex, I don't know what they're afraid of.
Hey, all that sounds good and stuff. I dare you to suggest that during rounds. Really...put your reputation up for it man...don't just talk...walk the walk.
I mean... his point is valid. For all you know, he does have that rapport, and does make such suggestion...
If the doctor is going way off label with their dosing, I 100% will play along.
As a fellow pharmacist, I'll give him that. I was just making a point that you shouldn't subject a patient to additional therapy and AE's just to block one drug's potential effects. There has to be evidence. Celebrex has been around for a while and even in the hayday of Vioxx and its frivolous use and aftermath, I have yet to see any doctor prescribe an anti-platelet agent just to counteract...and yes I have seen 400mg BID before.
If he makes such a wild suggestion like that...he should be ready to back it up with hard core evidence, not Wikipedia-like descriptions of pathways and such. We practice evidence-based medicine, not books.
I agree with you on that point, as well. To be honest, I forgot the original reason you posted "opposing" him/her, and this cleared it up.
There aren't studies because the dose is ridiculous. My evidence-based recommendation is lower the dose and/or use a different drug. If the doc wants this dose and the patient has an MI, my note that "recommended antiplatelet, MD declined" is enough evidence-based proof that I'm not liable in a malpractice claim.
Wait, am I missing something here? Isn't Celebrex an NSAID which is COX-2 selective? Doesn't it have an increased risk of bleeding? Even if the pathways you mention are all true in petri dishes, it's not clinically significant. Isn't the clinically significant effect increased risk of bleeding? That's why people on Celebrex may bleed more or if they get a cut it takes longer for it to clot.
No. You've got it backwards. Cox-1 inhibition increases bleed risk (see: aspirin).
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what @zelman said. celebrex doesn't decrease platelet aggregation
...or he will take you up on the recommendation and now you have a patient who is on Celebrex and prophylactic Plavix, which no current data supports. The patient is hospitalized for some random bleeding and now you and the doctor got a lawsuit on your hands. Just saying....arggg you know what...I take it back....you probably won't be implicated in such a case...they will settle out of court and it should be good.
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What bloodwork, specifically?
A fair point. But, if I wanted to avoid all ADE's at all costs, I'd be recommending homeopathy. It's not a situation with a clearly correct solution. Keep in mind that my suggestion was for "an antiplatelet...or something." My example was an antiplatelet at below half the normal dose, but that was just an example of something one might consider. An even more conservative option would be 81mg aspirin and people would probably not argue me on that suggestion. But at that point, why waste the money on a COX-2 inhibitor? Just put them on meloxicam and get the same effect at a tenth the price. Basically, I'm open to discussing suggestions based on evidence or conjecture, and I just threw something out there to get the ball rolling. Now, anyone ready to suggest dipyridamole?
