Alternatives to Vioxx if Heart
Although the sudden decision to withdraw Vioxx came as a surprise,
it wasn't entirely unexpected. Concerns about the cardiovascular safety
of this medication were raised soon after it was approved for sale
in the United States .
As of this early October 2004 article, hard and fast guidelines for
replacing Vioxx haven't yet been published. What many doctors are telling
their patients with heart disease is to first try one of the older, more
established anti-inflammatory drugs.
Many people turned to the new drugs, called COX-2 inhibitors, because
they thought they were superior for relieving pain or easing inflammation.
In reality, Vioxx, Celebrex, or Bextra aren't any better at this than
older and much less expensive nonsteroidal anti-inflammatory drugs (NSAIDs)
such as aspirin, ibuprofen (Advil, Motrin, others), and naproxen (Aleve,
Naprosyn, others). Like the older drugs, the COX-2 inhibitors can also
irritate the stomach. Their main advantage is that they aren't as likely
to cause bleeding ulcers. Keep in mind, though, that this "advantage" is
small and far from complete - about 1%-2% of people who use an older
NSAID develop serious stomach bleeding, compared to 0.5%-1% of those
using a COX-2 inhibitor.
When questions were first raised about the cardiovascular safety of
Vioxx, some experts attributed problems to the fact that people taking
Vioxx weren't taking aspirin. We now know that the COX-2 inhibitors,
like all NSAIDs, can strain the heart by causing the kidneys to hold
onto water and increasing blood pressure. There is another more worrisome
possibility. Instead of preventing platelets from sticking to each other,
as aspirin does, Vioxx may actually encourage platelets to clump. This
would promote clot formation and increase the chances of having a heart
attack or stroke.
The possibility exists that Celebrex and Bextra don't behave the same
way that Vioxx does. But as an opinion piece in The New England Journal
of Medicine put it, the burden of proof should be on the company
that makes these drugs to show that they don't pose a danger to cardiovascular
You clearly can't wait until all of the scientific issues have been
hashed out. So here is what I recommend for your joint pain today:
Avoid Celebrex or Bextra until you have given the older pain relievers
another try. Start with acetaminophen (Tylenol). For an amazing percentage
of problems, this drug is safe, effective, and inexpensive.
If acetaminophen doesn't do the job, try ibuprofen or naproxen. Tell
your doctor what you are doing because, like the COX-2 inhibitors,
these NSAIDs can raise your blood pressure and affect your kidney function.
The FDA is currently looking at recent evidence of potential heart
disease risk associated with naproxen. Until further information is
available, it recommends that patients adhere exactly to instructions
on the label.
If taking these drugs in the past caused gastrointestinal bleeding or
gave you an ulcer, you can protect your stomach with a proton pump inhibitor
such as over-the-counter omeprazole (Prilosec OTC). Combining an NSAID
with a proton pump inhibitor is also a good idea if you take an anticoagulant
such as warfarin or a steroid, have a high risk of bleeding due to a
low platelet count, or are elderly.
If all of these fail, then trying Celebrex or Bextra is certainly an option.
For most people, though, the old standbys offer a safer and cheaper way
to battle arthritis and other aches and pains.
January 2005 Update
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