Alternatives to Vioxx if Heart Disease Present

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 health.

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.

January 2005 Update

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