Medical Matters: For many people with arthritis - both the common wear and tear (osteoarthritis) and the less common but more serious rheumatoid arthritis - the past few months have been a period of uncertainty where anti-inflammatory medication is concerned.
While non-steroidal anti inflammatory drugs (NSAIDS) have no effect on the progression of either osteoarthritis (OA) or rheumatoid arthritis (RA), they have made the lives of those with the diseases more bearable.
So when the pharmaceutical company Merck announced the withdrawal of its NSAID Vioxx (rofecoxib) in late September, because of evidence that its use was associated with an increased incidence of heart attack and stroke, doctors and patients began to worry about other new generation NSAIDS.
Drugs such as rofecoxib, valdecoxib and celecoxib are Cox 2 inhibitors. This means they work by blocking the effect of one form of the enzyme cyclooxygenase (Cox). The older NSAIDS block a different form of the enzyme, Cox I. All forms of cyclooxygenase help make substances called prostaglandins. These chemicals are involved in the inflammatory process, such as that present in joints affected by OA or RA. But researchers discovered that Cox 2 inhibitors selectively blocked the anti-inflammatory effect of prostaglandins without interfering with some of the desired effect of the chemicals, such as protecting the stomach and small intestine from developing ulcers.
This was a significant risk with the original Cox 1 NSAIDS and the development of the Cox 2 drugs was hailed as a major breakthrough. However, in the rush to bring the new drugs to market - it has been suggested that the Food and Drug Administration (FDA) in the US fastracked the process - the different clotting effects of the Cox 1 and Cox 2 appear to have been forgotten about.
Cox 1 helps prevent clotting. Cox 2 inhibits the formation of blood clots. If you block Cox 2, the overall effect is to promote thrombosis. As Dr Garrett Fitzgerald, professor of pharmacology at the University of Pennsylvania's School of Medicine, has noted: "All three of the [US] approved coxibs inhibit prostaglandin 12 formation and therefore would be expected to elevate blood pressure, accelerate plaque formation and predispose patients to an exaggerated thrombotic response."
Dr Fitzgerald was also quick to suggest that the cardiovascular concerns surrounding Vioxx would also apply to other drugs in the class. It was therefore no surprise when Pfizer announced in December that a trial involving one of its Coxs, Celebrex (celecoxib), had found there was a two and a half times increased risk of stroke or heart attack in people taking Celebrex 400mg daily. Patients were on the medication for an average 33 months.
Unlike Merck, Pfizer has not withdrawn the drug from the marketplace. But it has written to doctors advising them to consider "discussing appropriate treatment options with their patients being treated with Celebrex".
So what should people on long- term treatment with Cox 2 inhibitors do? If you have a history of angina, previous heart attack or stroke, it would seem prudent to discuss stopping the new generation anti-inflammatories with your doctor. If you suffer with heart failure or are prone to fluid retention, then any type of NSAID is likely to make this worse, and again you should discuss alternatives with your doctor.
What are your options? You could consider returning to an old fashioned NSAID, although just before Christmas concern was raised about possible cardiovascular effects associated with one of these, Naproxen. Be aware also of the well-established risk of gastrointestinal bleeding with Cox 1 NSAIDS. If you can tolerate aspirin, it has clear cardiac benefits as well as being a pain reliever.
For those with severe inflammation and pain, it may be necessary to stick with an NSAID, but only after discussing your individual risk profile with your doctor. And for people with relatively mild osteoarthritis, it may well be time to consider the regular use of a simple analgesic such as paracetamol.
You should not forget the benefits of physiotherapy and occupational therapy either. Therapists can offer a range of non-pharmaceutical treatments to both OA and RA patients.
NSAIDS are widely used. One study in the Netherlands found that 10 per cent of the population there used NSAIDS other than aspirin. So the recent concerns over their side-effect profile represent a public health issue.
Readers may also be interested in a study just published in the British Medical Journal. It found that wearing a magnetic bracelet reduced pain in people with OA of the hip and knee. No one knows why and the research needs to be replicated in a larger group of patients, but it may be a non-drug option you would like to explore.
Dr Muiris Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he cannot answer individual queries.