Page 109 - Athletic Health Handbook
P. 109
2.5 million individuals in the United Table 2: Patient risk factors for an
States experience adverse renal effects adverse GI event with NSAID use
attributed to NSAID use.18 Although
COX-2 inhibitor agents may Over age 60 years
demonstrate a lower risk of GI injury
when compared to COX-1 NSAIDs, Previous gastrointestinal event
COX-2 NSAIDs still pose a small
risk of gastrointestinal bleeding.19,20 Concomitant steroid or anticoagulant use

Conflicting Labeling of Within the firstt 3 months of therapy
Non-Selective and COX-2
Selective NSAIDs Higher NSAID dose

In the last five years, there has been Common NSAIDs
intense interest in the cardiovascular,
gastrointestinal, and renal effects of Generic Name Trade Name
both COX-2 inhibitors and COX-1 Celecoxib
NSAIDs. Regulatory authorities have Diclofenac Celebrex
provided variable advice regarding Diflunisal Cataflam, Voltaren, Arthrotec (+ misoprostol)
the safety of these drugs. In the Etodolac Dolobid
United States, the FDA requires Fenoprofen Lodine, Lodine XL
that both COX-2 inhibitors and Flurbirofen Nalfon, Nalfon 200
NSAIDs carry a warning highlighting Ibuprofen Ansaid
the potential for increased risk of Motrin, Tab-Profen, Vicoprofen (+ hydrocodone),
cardiovascular events.21 In contrast, Indomethacin Combunox (combined with oxycodone)
the European Medicines Agency Indocin, Indocin SR, Indo-Lemmon,
requires labeling of selective COX-2 Ketoprofen Indomethagan
inhibitors but requires no such Ketorolac Oruvail
labeling regarding cardiovascular Mefenamic Acid Toradol
safety of COX-1 NSAIDs.22,23 Meloxicam Ponstel
Nabumetone Mobic
Cardiovascular and Renal Naproxen Relafen
Effects of COX-2 Inhibitors Naprosyn, Anaprox, Anaprox DS, EC-Naproxyn,
and Non-Selective NSAIDs Oxaprozin Naprelan, Naprapac (+ lansoprazole)
Piroxicam Daypro
Zhang et al24 reviewed all published Sulindac Feldene
double-blind randomized clinical Tolmetin Clinoril
trials of COX-2 inhibitors. When Tolectin, Tolectin DS, Tolectin 600
compared to controls, rofecoxib
(Vioxx™) was associated with McGettigan et al25 performed a with an elevated risk of vascular
an increased risk of arrhythmia meta-analysis comparing the risks occlusion (RR=1.06). Insufficient
(RR=2.90) while adverse renal events of serious cardiovascular events data prevented the calculation of
were associated with a greater dose associated with COX-1 and COX-2 effects at different doses. Among the
and duration of treatment (p< 0.05). NSAIDs. The authors found a dose- older NSAIDs, all had relative risks
In contrast, celecoxib (Celebrex™) related risk with rofecoxib beginning close to 1 except diclofenac (RR=1.4).
was associated with a lower risk of at 25 mg/day (RR=1.33). This risk
renal dysfunction (RR=0.61) and doubled when rofecoxib was increased Kearney et al26 reported a meta-
hypertension (RR=0.83) compared to 50 mg/day and was noted within analysis of randomized trials examin-
to controls and the effect did not the first month of treatment. In ing the effects of NSAIDs on
appear to be dose dependent. No contrast, celecoxib was not associated cardiovascular health. Acute MI
adverse effects on renal function and was increased with rofecoxib at
blood pressure were observed with
other COX-2 agents.

COX-2 INHIBITORS AND NON-SELECTIVE NSAIDS 109
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