Canadian Rheumatology Association issues statement on Vioxx alternatives

The Canadian Rheumatology Association (CRA) has issued a statement to its 350 members and other interested parties, recommending alternative treatment considerations in the wake of the worldwide recall of Merck's rofecoxib, (Vioxx(R)) last week.

"With millions of Canadians being affected by the Vioxx withdrawal, we believe it is important to provide their health professionals with important considerations when prescribing alternatives," explained CRA President Michel Zummer, MD, FRCPC. The statement has been posted on the CRA web site (www.cra- scr.ca) and has been issued to medical and pharmacy associations across the country.

The CRA statement recommends that all patients taking Vioxx, a cyclooxygenase II selective inhibitor (Coxib), discontinue its use and contact their prescribing physician about an alternative, which may include another coxib or non-steroidal anti-inflammatory (NSAID) medication. It also urges physicians and pharmacists to make all possible efforts to arrange for their patients to discontinue Vioxx.

While there is no published evidence as to ideal alternative treatments, the CRA urges health professionals to consider the following when making a decision to switch their patient to another analgesic, such as a NSAID or another Coxib:

1. There is no data to date that other NSAIDs or coxibs have caused cardiovascular problems similar to Vioxx. Pfizer conducted a similar prospective randomized controlled trial with high dose celecoxib vs. placebo and did not report an increase in myocardial infarctions.(1)
2. NSAIDs which are primarily COX I-selective, such as ibuprofen and indomethacin, could interfere with the effectiveness of aspirin in preventing arterial thrombotic events.(2) NSAIDs which are more COX II-selective (diclofenac, etodolac, nabumetone, meloxicam) are less likely to have this interaction.
3. Patients should be evaluated for their risk of an arterial thrombotic event (stroke, MI) when making a decision as to which alternative NSAID or coxib to use.
4. Patients should also be evaluated for their risk of gastrointestinal (GI) ulceration and bleeding and more importantly other illnesses that could result in the inability to tolerate this. These patients will require a Proton Pump Inhibitor (esomeprazole, lansoprazole, omeprazole, pantoprazole) in conjunction with their NSAID, or treatment with a more selective Coxib, or in some cases a topical NSAID.
5. Both celecoxib and valdecoxib are relatively contraindicated in patients with sulpha allergies.

Rheumatologists, as specialists in the branch of internal medicine that deals with diseases of the joints, connective tissues of the body, and illnesses that are rheumatic in nature, are experts in arthritis care. The CRA represents 350 Canadian rheumatologists and promotes their pursuit of excellence in arthritis care and research in Canada through leadership, education and communication.