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Panel discussion: treatment approaches to control gastrointestinal risk and balance cardiovascular risks and benefits: proposals and recommendations 小组讨论:控制胃肠道风险和平衡心血管风险和益处的治疗方法:提案和建议
Pub Date : 2005-08-26 DOI: 10.1111/j.1746-6342.2005.00018.x
J. M. SCHEIMAN, B. CRYER, M. ASAKA, F. BERENBAUM, J. BONNET, F. K.-L. CHAN, G. KREJS, A. LANAS, A. WEAVER, F. ZERBIB
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引用次数: 4
Chairmen's introduction 主席的介绍
Pub Date : 2005-08-26 DOI: 10.1111/j.1746-6342.2005.00011.x
J. M. Scheiman, B. Cryer
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引用次数: 0
Review article: a cardiologist's view of the risks and benefits of cyclo-oxygenase-2 inhibitors, aspirin and other non-steroidal anti-inflammatory drugs 综述文章:心脏病专家对环氧化酶-2抑制剂、阿司匹林和其他非甾体抗炎药的风险和益处的看法
Pub Date : 2005-08-26 DOI: 10.1111/j.1746-6342.2005.00014.x
J. BONNET
Cyclo-oxygenase-2 inhibitors are very interesting drugs, capable of inhibiting, the main source of inflammatory prostaglandins in the joint while also avoiding gastrointestinal complications. Unfortunately, double-blind studies have clearly demonstrated that cyclo-oxygenase-2 agents increase cardiovascular risk. This phenomenon appears to be a class effect although it seems to be less pronounced with celecoxib. These adverse cardiovascular events are mainly due to an elevated thrombotic risk and are possibly linked to the increase in blood pressure. The decision about whether to continue with cyclo-oxygenase-2 treatment can only be undertaken after consideration of both the cardiovascular risk and the gastrointestinal risk of an individual patient. In contrast, low-dose aspirin continues to be the simplest and most effective way to prevent cardiovascular disease. However, the increased risk of adverse gastrointestinal events associated with aspirin use, such as gastrointestinal bleeding and intracerebral bleeding, must not be forgotten. Ideally, the prescription of low-dose aspirin should be avoided for low cardiovascular risk patients and reserved for those patients with high or intermediate cardiovascular risk. In these patients, the risk of gastrointestinal events should prompt the prescription of a gastroprotectant, such as a proton-pump inhibitor, to be taken concomitantly, which will help avoid the significant problem of non-compliance in high cardiovascular risk patients.
环氧化酶-2抑制剂是一种非常有趣的药物,能够抑制关节炎症性前列腺素的主要来源,同时也避免了胃肠道并发症。不幸的是,双盲研究清楚地表明,环氧化酶-2药物增加心血管风险。这种现象似乎是一种类效应,尽管塞来昔布似乎不那么明显。这些不良心血管事件主要是由于血栓形成风险升高,并可能与血压升高有关。是否继续环氧化酶-2治疗的决定只能在考虑心血管风险和个体患者胃肠道风险后进行。相反,低剂量阿司匹林仍然是预防心血管疾病最简单、最有效的方法。然而,不能忘记与阿司匹林使用相关的胃肠道不良事件的风险增加,如胃肠道出血和脑出血。理想情况下,低心血管风险患者应避免处方低剂量阿司匹林,并保留给那些高或中度心血管风险的患者。在这些患者中,胃肠道事件的风险应提示患者同时服用胃保护剂,如质子泵抑制剂,这将有助于避免高危心血管患者不遵规的重大问题。
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引用次数: 1
Review article: clinical management of non-steroidal anti-inflammatory drug and cyclo-oxygenase-2 inhibitor users: a European perspective 综述文章:非甾体抗炎药和环氧化酶-2抑制剂使用者的临床管理:欧洲视角
Pub Date : 2005-08-26 DOI: 10.1111/j.1746-6342.2005.00013.x
F. BERENBAUM

Following the withdrawal of rofecoxib from the market in September 2004, the European Medicines Evaluation Agency's prescribing recommendations for cyclo-oxygenase-2 inhibitors were quite similar to those issued by the US Food and Drug Administration. Prior to this event the perceptions and guidelines for use of cyclo-oxygenase-2 agents varied between the different countries, however the cardiovascular concerns that were raised about the cyclo-oxygenase-2 inhibitor class prompted a dramatic shift in perception and a significant switch to the use of traditional non-steroidal anti-inflammatory drugs.

There is little doubt that non-steroidal anti-inflammatory drugs are effective in relieving pain and inflammation in conditions such as rheumatoid arthritis and osteoarthritis, however they are known to be associated with gastrointestinal adverse events. In order to avoid these gastrointestinal risks, the clinician may choose to prescribe an analgesic agent such as paracetamol as an alternative, or add a gastroprotective agent, such as a proton-pump inhibitor to the non-steroidal anti-inflammatory drug therapy. Whether the patient takes aspirin also needs to be considered: while aspirin is often taken for prophylaxis against cardiovascular events, it is itself associated with gastrointestinal risks and has been shown to eliminate the gastrointestinal sparing effects of cyclo-oxygenase-2 agents.

In the light of this evidence many national rheumatology societies in Europe have now issued recommendations for the use of cyclo-oxygenase-2 inhibitors and conventional non-steroidal anti-inflammatory drugs based on the patient's individual risk profile.

在2004年9月罗非昔布从市场上撤出后,欧洲药品评估局对环氧合酶-2抑制剂的处方建议与美国食品和药物管理局发布的建议非常相似。在此事件之前,不同国家对使用环氧化酶-2药物的看法和指南各不相同,然而,对环氧化酶-2抑制剂类提出的心血管问题促使看法发生了巨大转变,并显著转向使用传统的非甾体抗炎药。毫无疑问,非甾体类抗炎药在缓解类风湿性关节炎和骨关节炎等疾病的疼痛和炎症方面是有效的,然而,它们已知与胃肠道不良事件有关。为了避免这些胃肠道风险,临床医生可能会选择开一种镇痛药,如扑热息痛作为替代,或在非甾体抗炎药物治疗中添加胃保护剂,如质子泵抑制剂。患者是否服用阿司匹林也需要考虑:虽然阿司匹林经常用于预防心血管事件,但它本身与胃肠道风险相关,并且已被证明可以消除环氧化酶-2药物的胃肠道保留作用。鉴于这一证据,欧洲许多国家风湿病学会现已根据患者的个体风险概况发布了使用环氧化酶-2抑制剂和传统非甾体抗炎药的建议。
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引用次数: 0
Review article: low-dose aspirin, non-steroidal anti-inflammatory drugs and cyclo-oxygenase inhibitors – balancing risks and benefits 综述文章:低剂量阿司匹林,非甾体抗炎药和环加氧酶抑制剂-平衡风险和收益
Pub Date : 2005-08-26 DOI: 10.1111/j.1746-6342.2005.00016.x
F. K.-L. CHAN

In recent years, there has been a rapid increase in the number of patients using aspirin for the prevention of cardiovascular events and also other non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, for the treatment of arthritis. However, aspirin and non-steroidal anti-inflammatory drugs are associated with an increase in gastrointestinal risk. Recent studies have shown that cyclo-oxygenase-2 inhibitors, and possibly non-selective non-steroidal anti-inflammatory drugs, increase the cardiovascular risk.

In patients taking aspirin, the ‘gold standard’ therapy to reduce gastrointestinal risk is concomitant therapy with a gastroprotective agent, such as a proton-pump inhibitor. Other gastroprotective agents, such as misoprostol, while equally effective may be associated with a higher proportion of adverse events. Helicobacter pylori infection has been shown to increase the risk of upper gastrointestinal bleeding associated with low-dose aspirin. Emerging data suggest that the eradication of H. pylori reduces the gastrointestinal risk of high-risk aspirin users. Other antiplatelet agents such as clopidogrel that were thought to be non-ulcerogenic have been widely used as alternatives to aspirin. However, recent studies have shown that clopidogrel induces an unacceptably high rate of ulcer bleeding in high-risk patients.

When prescribing non-steroidal anti-inflammatory drugs therapy, treatment needs to be individualized according to the patients’ gastrointestinal and cardiovascular risk factors.

近年来,使用阿司匹林预防心血管事件和其他非甾体抗炎药(包括环氧化酶-2抑制剂)治疗关节炎的患者数量迅速增加。然而,阿司匹林和非甾体抗炎药与胃肠道风险增加有关。最近的研究表明,环氧化酶-2抑制剂,可能是非选择性非甾体抗炎药,增加心血管风险。对于服用阿司匹林的患者,降低胃肠道风险的“金标准”疗法是与胃保护剂(如质子泵抑制剂)联合治疗。其他胃保护剂,如米索前列醇,虽然同样有效,但可能与较高比例的不良事件相关。幽门螺杆菌感染已被证明会增加与低剂量阿司匹林相关的上消化道出血的风险。新出现的数据表明,根除幽门螺旋杆菌可以降低高风险阿司匹林使用者的胃肠道风险。其他抗血小板药物如氯吡格雷被认为不会引起溃疡,已被广泛用作阿司匹林的替代品。然而,最近的研究表明,氯吡格雷在高危患者中引起溃疡出血的发生率高得令人无法接受。在处方非甾体类抗炎药治疗时,需要根据患者的胃肠道和心血管危险因素进行个体化治疗。
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引用次数: 0
Review article: aspirin, non-steroidal anti-inflammatory drugs and cyclo-oxygenase-1 sparing agents 综述文章:阿司匹林,非甾体抗炎药和环氧化酶-1保留剂
Pub Date : 2005-08-26 DOI: 10.1111/j.1746-6342.2005.00012.x
A. L. WEAVER

Until recently, cyclo-oxygenase-2 inhibitors were one of the mainstays of therapy for patients with osteoarthritis and rheumatoid arthritis because of their improved gastrointestinal safety profile compared with traditional, non-selective non-steroidal anti-inflammatory drugs.

The withdrawal of both rofecoxib and valdecoxib from the market because of concerns about cardiovascular risk has prompted a re-evaluation of treatment choices for arthritis patients who require treatment with non-steroidal anti-inflammatory drugs. Non-steroidal anti-inflammatory drugs, both prescription and over-the-counter, are widely used in the USA. Patients often take several agents concurrently which significantly increases their risk of gastrointestinal adverse events. In addition, many patients also take low-dose aspirin because of its proven beneficial effects in the prevention of cardiovascular events. However, large clinical trials have shown that the concomitant use of aspirin negates the gastrointestinal-sparing effects of selective cyclo-oxygenase-2 inhibitors.

Clinicians need to consider a patient's cardiovascular and gastrointestinal risks when prescribing non-steroidal anti-inflammatory drugs, and in the case of non-selective non-steroidal anti-inflammatory drugs, gastroprotection with an agent such as a proton-pump inhibitor or misoprostol should be considered, particularly in aspirin users.

直到最近,环氧化酶-2抑制剂是治疗骨关节炎和类风湿关节炎患者的主要药物之一,因为与传统的非选择性非甾体抗炎药相比,环氧化酶-2抑制剂改善了胃肠道安全性。由于担心心血管风险,罗非昔布和伐地昔布都从市场上撤出,这促使人们重新评估需要使用非甾体类抗炎药治疗的关节炎患者的治疗选择。非甾体类抗炎药,无论是处方药还是非处方药,在美国都被广泛使用。患者经常同时服用几种药物,这大大增加了胃肠道不良事件的风险。此外,许多患者还服用低剂量阿司匹林,因为它被证明对预防心血管事件有益。然而,大型临床试验表明,同时使用阿司匹林否定了选择性环氧化酶-2抑制剂的胃肠道保护作用。临床医生在开非甾体类抗炎药时需要考虑患者的心血管和胃肠道风险,在非选择性非甾体类抗炎药的情况下,应考虑使用质子泵抑制剂或米索前列醇等药物来保护胃,尤其是阿司匹林使用者。
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引用次数: 1
Review article: a summary of studies of non-steroidal anti-inflammatory drug-induced gastrointestinal complications in Japanese patients 综述文章:日本患者非甾体抗炎药引起的胃肠道并发症的研究综述
Pub Date : 2005-08-26 DOI: 10.1111/j.1746-6342.2005.00017.x
M. ASAKA
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引用次数: 0
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