Review article: clinical management of non-steroidal anti-inflammatory drug and cyclo-oxygenase-2 inhibitor users: a European perspective

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.