Risk of myocardial infarction in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis

Risk of myocardial infarction and death associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) among healthy individuals: a nationwide cohort study

Use of some nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with increased cardiovascular risk in several patient groups, but whether this excess risk exists in apparently healthy individuals has not been clarified. Using a historical cohort design, we estimated the risk of death and myocardial infarction associated with the use of NSAIDs. Participants in the study were selected from the Danish population and were defined as healthy according to a history of no hospital admissions and no concomitant selected pharmacotherapy. The source population consisted of 4,614,807 individuals, of whom 1,028,437 were included in the study after applying selection criteria. Compared to no NSAID use, hazard ratios (95% confidence limits) for death/myocardial infarction were 1.01 (0.96-1.07) for ibuprofen, 1.63 (1.52-1.76) for diclofenac, 0.97 (0.83-1.12) for naproxen, 2.13 (1.89-2.41) for rofecoxib, and 2.01 (1.78-2.27) for celecoxib. A dose-dependent increase in cardiovascular risk was seen for selective COX-2 inhibitors and diclofenac. Caution should be exercised in NSAID use in all individuals, and particularly high doses should be avoided if possible.

The pattern of use of non-steroidal anti-inflammatory drugs (NSAIDs) from 1997 to 2005: a nationwide study on 4.6 million people

PURPOSE

To describe the nationwide pattern of use of non-steroidal anti-inflammatory drugs (NSAIDs) in the Danish population.

METHODS

All Danish citizens aged 10 or above 1 January 1997 were included in the study. The national prescription registry was used to identify all claimed prescriptions for NSAIDs by the cohort until 2005. By individual-level-linkage of nationwide registries, information was acquired concerning hospitalizations, comorbidity, concomitant pharmacotherapy and socioeconomic factors.

RESULTS

The population consisted of 4,614,807 individuals, of which 2,663,706 (57.8%) claimed at least one prescription for NSAID from 1997 to 2005. Ibuprofen and diclofenac were the most frequently used non-selective NSAIDs, whereas rofecoxib and celecoxib were the most frequently used selective cyclooxygenase-2 (COX-2) inhibitors. The usage was similar across all age groups. Female sex and increasing age was associated with increased use of NSAID. Factors predicting extensive NSAID use were: rheumatic disease (odds ratio (OR) = 1.79, 95% confidence interval (CI): 1.69-1.90), gout agents (allopurinol) (OR = 2.54, CI: 2.44-2.64) and other pain medication (OR = 3.27, CI: 3.23-3.31). NSAIDs were most often prescribed for use for one distinct treatment interval and for a short period (overall inter-quartile range [IQR]: 9-66 days). High doses were used in a relatively large proportion of the population (8.9% for etodolac to 19.5% for celecoxib) and 54,373 (2.0%) claimed prescriptions for more than one NSAID at the same time.

CONCLUSION

NSAIDs were commonly used in the Danish population. Since NSAIDs have been associated with increased cardiovascular risk, further research on the overall risk associated with these drugs on a national scale is needed.

Management of chronic knee pain: a survey of patient preferences and treatment received

Background

A range of interventions exist for the management of knee pain, but patient preferences for treatment are not clear. In this study the management received by people with chronic knee pain, their management preferences and reasons for these preferences were recorded.

Methods

At baseline assessment of a clinical trial of rehabilitation for chronic knee pain, 415 participants were asked about their i) previous management, ii) preferred treatment, if any, iii) whether they would undergo knee surgery and iv) reasons for their preferences.

Results

Previous management – Medication was the most common treatment, followed by physiotherapy, 39 participants had received no treatment. Preferences – 166 patients expressed no treatment preference. Of those who expressed a preference the most popular option was physiotherapy, whilst not having surgery was the third most frequent response. The most common reason for preferring physiotherapy and not wanting surgery was prior experience.

Willingness to accept surgery – 390 participants were not waiting for knee replacement surgery, and overall 81% would not accept surgery if offered, usually because pain was not perceived to be severe enough to warrant surgery.

Conclusion

Most chronic knee pain is managed with medication despite concerns about safety, efficacy and cost, management guidelines recommendations and people's management preferences. Previous experience and perceptions of need were major determinants of people's preferences, but many people were unaware of management options. Appreciating patient preferences and provision of more information about management options are important in facilitating informed patient/clinician discussion and agreement.

Trial Registration

Current Controlled Trials, ISRCTN 94658828

Cardiovascular, rheumatologic, and pharmacologic predictors of stroke in patients with rheumatoid arthritis: a nested, case-control study

OBJECTIVE

To determine the risk of stroke in patients with rheumatoid arthritis (RA) and risk factors associated with stroke.

METHODS

We performed nested case-control analyses within a longitudinal databank, matching up to 20 controls for age, sex, and time of cohort entry to each patient with stroke. Conditional logistic regression was performed as an estimate of the relative risk of stroke in RA patients compared with those with noninflammatory rheumatic disorders, and to examine severity and anti-tumor necrosis factor (anti-TNF) treatment effects in RA.

RESULTS

We identified 269 patients with first-ever all-category strokes and 67 with ischemic stroke, including 41 in RA patients. The odds ratio (OR) for the risk of all-category stroke in RA was 1.64 (95% confidence interval [95% CI] 1.16-2.30, P = 0.005), and for ischemic stroke was 2.66 (95% CI 1.24-5.70, P = 0.012). Ischemic stroke was predicted by hypertension, myocardial infarction, low-dose aspirin, comorbidity score, Health Assessment Questionnaire score, and presence of total joint replacement, but not by diabetes, smoking, exercise, or body mass index. Adjusted for cardiovascular and RA risk factors, ischemic stroke was associated with rofecoxib (P = 0.060, OR 2.27 [95% CI 0.97-5.28]), and possibly with corticosteroid use. Anti-TNF therapy was not associated with ischemic stroke (P = 0.584, OR 0.80 [95% CI 0.34-1.82]).

CONCLUSION

RA is associated with increased risk of stroke, particularly ischemic stroke. Stroke is predicted by RA severity, certain cardiovascular risk factors, and comorbidity. Except for rofecoxib, RA treatment does not appear to be associated with stroke, although the effect of corticosteroids remains uncertain.

Risk of ischaemic cardiovascular events from selective cyclooxygenase-2 inhibitors in osteoarthritis

PURPOSE

Most previous observational studies assessing cardiovascular risk associated with Cox-2 inhibitors (Cox-2is) used a case control approach, limiting the assessment of absolute risk by disease group and effect of duration of exposure. We conducted a retrospective cohort study in patients with osteoarthritis.

METHODS

Using the Life-link US claims database, all subjects had at least five years history in the database. Exposure was defined as the first chronic period of Cox-2i (celecoxib, rofecoxib or valdecoxib) or naproxen use. Non-users and non-chronic users of non-steroidal anti-inflammatory drug (NSAID)/Cox-2i within the osteoarthritis cohort served as the reference. The primary outcome was myocardial infarction and ischaemic stroke.

RESULTS

A cohort of 16,580 subjects were chronically exposed to celecoxib, 9800 received rofecoxib, 2907 received naproxen and 51,539 were non-chronically exposed controls. With a median follow up of 506 days, there were 2116 ischaemic events for the entire cohort. The strongest predictors of AMI/ ischaemic stroke risk were history of ischaemic stroke (HR 2.34, 2.12-2.59) and age 65+ years (HR 2.28, 2.07-2.52). For rofecoxib, (HR 1.25,1.04-1.50), the attributable risk varied from 3 per 1000 patients years in individuals aged under 65 years with no history of CVD to 19 per 1000 patients years in older individuals with a history of CVD. The hazard ratios did not change over time. Celecoxib and naproxen were not associated with increased risks.

CONCLUSIONS

The attributable risk for rofecoxib varied substantially with the underlying cardiovascular risk profile, being lower in clinical trial than in clinical practice populations.

Cardiovascular risks of COX inhibition: current perspectives

BACKGROUND

NSAIDs are among the most commonly used pharmacotherapeutic agents worldwide. As the long-term use of these drugs is associated with serious gastrointestinal side effects, a new subgroup of COX-2 selective NSAIDs was developed. It was thought that the therapeutic strategy underlying the development of these newer compounds would enable them to provide the same analgesic and anti-inflammatory benefits as those of their traditional counterparts but perhaps offer a much safer gastrointestinal profile. Much scientific data has accumulated over the last few years, however, raising concerns regarding the increased cardiovascular complications associated with the use of COX-2 selective NSAIDs, and perhaps of the traditional NSAIDs as well.

OBJECTIVE

To review current and emerging evidence related to the cardiovascular effects of COX inhibitors and examine the clinical implications.

METHOD

We studied data from basic clinical research, non-randomized analyses, and randomized trials of COX inhibitors that investigated their cardiovascular effects.

CONCLUSION

Both COX-2 selective and traditional NSAIDs are associated with a moderately increased risk of cardiovascular events.

Cyclooxygenase 2-selective and nonselective nonsteroidal anti-inflammatory drugs induce oxidative stress by up-regulating vascular NADPH oxidases

Cyclooxygenase 2-selective inhibitors (coxibs) and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with an increase in cardiovascular events. The current study was designed to test the effect of coxibs and nonselective NSAIDs on vascular superoxide and nitric oxide (NO) production. mRNA expression of endothelial NO synthase (eNOS) and of the vascular NADPH oxidases was studied in spontaneously hypertensive rats (SHR) and in human endothelial cells. The expression of Nox1, Nox2, Nox4, and p22phox was increased markedly by the nonselective NSAIDs diclofenac or naproxen and moderately by rofecoxib or celecoxib in the aorta and heart of SHR. The up-regulation of NADPH oxidases by NSAIDs was associated with increased superoxide content in aorta and heart, which could be prevented by the NADPH oxidase inhibitor apocynin. NSAIDs reduced plasma nitrite and diminished the phosphorylation of vasodilator-stimulated phosphoprotein. This demonstrates a reduction in vascular NO production. Aortas from diclofenac-treated SHR showed an enhanced protein nitrotyrosine accumulation, indicative of vascular peroxynitrite formation. Peroxynitrite can uncouple oxygen reduction from NO synthesis in eNOS. Accordingly, the eNOS inhibitor N(G)-nitro-L-arginine methyl ester reduced superoxide content in aortas of NSAID-treated animals, demonstrating eNOS uncoupling under those conditions. Also in human endothelial cells, NSAIDs increased Nox2 expression and diminished production of bioactive NO. In healthy volunteers, NSAID treatment reduced nitroglycerin-induced, NO-mediated vasodilatation of the brachial artery. These results indicate that NSAIDs may increase cardiovascular risk by inducing oxidative stress in the vasculature, with nonselective NSAIDs being even more critical than coxibs in this respect.

Prescribing pattern of drugs in the treatment of osteoarthritis in Italian general practice: the effect of rofecoxib withdrawal

OBJECTIVE

In October 2004, rofecoxib was removed from the world market because of an increased risk of myocardial infarction. The aim of the present study was to compare the trend of nonsteroidal antiinflammatory drug (NSAID) use and other analgesics in osteoarthritis (OA) treatment before and after rofecoxib withdrawal in Italian general practice.

METHODS

From the Caserta-1 Local Health Service database, 97 general practitioners were recruited. Prevalence and incidence of use of any study drug were calculated within 1 year before and after rofecoxib withdrawal.

RESULTS

One-year prevalence of nonselective and preferential NSAID use did not change after rofecoxib withdrawal, whereas coxib use fell from 4.4% (95% confidence interval [95% CI] 4.2-4.5%) in the period before rofecoxib withdrawal (period I) to 1.6% (95% CI 1.5-1.7%) in the period after withdrawal (period II). Weak opioids were used in no more than 0.4% (95% CI 0.3-0.5%) in period II, after their introduction to reimbursement in December 2004. Also, 1-year incidence of coxib decreased from 31.3 per 1,000 (95% CI 30.2-32.4%) in period I to 8.7 per 1,000 (95% CI 8.1-9.2%) in period II. The disappearance of rofecoxib was associated with replacement drugs such as newly marketed dexibuprofen and aceclofenac, whereas nimesulide use coincidentally decreased.

CONCLUSION

Rofecoxib withdrawal has markedly changed the prescribing pattern of drugs that are used in OA-related pain treatment, with a striking decrease of coxib use in Italian general practice. Education strategies addressed to health professionals should be planned to improve the management of pain treatment, particularly in degenerative joint diseases.

Cyclooxygenase-2 inhibitors and most traditional nonsteroidal anti-inflammatory drugs cause similar moderately increased risks of cardiovascular disease

Cyclooxygenase-2 inhibitors relieve pain from inflammatory conditions by decreasing the gastrointestinal side effects from traditional nonsteroidal anti-inflammatory drugs. Basic research provided plausible mechanisms and some observational epidemiological studies, case-control and cohort, indicated that patients prescribed with cyclooxygenase-2 inhibitors and nonsteroidal anti-inflammatory drugs had increased risks for myocardial infarction and stroke. Because patients prescribed with cyclooxygenase-2 inhibitors were systematically different, uncontrolled and uncontrollable confounding by indication was as large as the observed risks. Thus, epidemiological studies or their meta-analyses could not discern whether, and if so, how much, the risks were real. A comprehensive meta-analysis of randomized trials indicated that cyclooxygenase-2 inhibitors increased the risk of vascular events by 42%, almost exclusively myocardial infarction, as did high-dose regimens of ibuprofen and diclofenac, but not naproxen. Individual clinical judgments and policy decisions should include cardiovascular disease and noncardiovascular disease risks including gastrointestinal side effects and clinical benefits including improved quality of life from less pain and disability.

N-terminal pro-B-type natriuretic peptide concentrations predict the risk of cardiovascular adverse events from antiinflammatory drugs: a pilot trial

BACKGROUND

we investigated whether higher concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) predicts cardiovascular adverse events (CV-AEs) in patients with osteoarthritis treated with antiinflammatory drugs.

METHODS

NT-proBNP was measured in baseline samples from 433 patients enrolled in a prospective randomized study designed to test the therapeutic effect of a novel metalloproteinase inhibitor. We monitored CV-AEs and retrospectively investigated their relationship to the concomitant use of selective cyclooxygenase-2 inhibitors (coxibs), traditional nonsteroidal antiinflammatory drugs (tNSAIDs), and glucocorticoids. CV-AEs included myocardial infarction, stroke, new or worsening of preexisting arterial hypertension, congestive heart failure, and several less severe CV-AEs.

RESULTS

we observed 82 mild to serious CV-AEs during an observational period of 200 days. The risk of such events was 1.95-fold higher in patients who were taking tNSAIDs, glucocorticoids, or coxibs (i.e., any inhibitor) and who had NT-proBNP concentrations > or = 100 ng/L than in patients taking any inhibitor who had NT-proBNP values <100 ng/L (P < 0.05). Patients taking coxibs (alone or in addition to tNSAIDs or glucocorticoids) with baseline NT-proBNP values > or = 100 ng/L had a 7.41-fold higher risk for CV-AEs than those with baseline values <100 ng/L (P < 0.01). Patients who were taking 2 or more antiinflammatory drugs and had NT-proBNP values > or = 100 ng/L had a 3.74-fold higher risk for CV-AEs than those with NT-proBNP values <100 ng/L (P < 0.05). An NT-proBNP value <100 ng/L was associated with negative predictive values of >85% across all treatment groups.

CONCLUSIONS

NT-proBNP may be a useful marker for anticipating cardiovascular risk associated with the use of antiinflammatory drugs for osteoarthritis.

Non-steroidal anti-inflammatory drug use does not appear to be associated with increased cardiovascular mortality in patients with inflammatory polyarthritis: results from a primary care based inception cohort of patients

Objectives:

There is controversy about the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on cardiovascular disease (CVD) mortality. The aim of this study was to explore associations between NSAID use and mortality in patients with inflammatory polyarthritis (IP).

Subjects and methods:

A total of 923 patients with new onset (IP), recruited to the UK Norfolk Arthritis Register (NOAR) between 1990–1994, were followed up to the end of 2004. Current medication was recorded annually for the first 6 years and then every 2–3 years. Rheumatoid factor (RF) and C-reactive protein (CRP) were measured. Logistic regression was used to calculate all cause and CVD mortality odds ratios (OR) for NSAID use at baseline and during follow-up, adjusting for gender and time-varying covariates: RF, CRP, joint counts, smoking, steroid use, DMARD use and other medication use.

Results:

By 2004 there were 203 deaths, 85 due to CVD. At baseline, NSAIDs were used by 66% of patients. In final multivariate models, baseline NSAID use was inversely associated with all cause mortality (adjusted OR 0.62, 95% CI 0.45 to 0.84) and CVD mortality (adjusted OR 0.54, 95% CI 0.34 to 0.86). Interval NSAID use had weaker mortality associations: all cause mortality (adjusted OR 0.72, 95% CI 0.52 to 1.00), CVD mortality (adjusted hazard ratio (HR) 0.66, 95% CI 0.40 to 1.08).

Conclusion:

No excess CVD or all cause mortality was observed in NSAID users in this cohort of patients with IP. This is at variance with the literature relating to NSAID use in the general population. It is unclear whether this represents unmeasured confounders influencing a doctor’s decision to avoid NSAIDs in the treatment of IP.

[Are there any differences in the cardiovascular tolerance between classical NSAIDs and coxibs?]

Three placebo-controlled studies have demonstrated deleterious cardiovascular (CV) effects of rofecoxib, celecoxib, and pare/valdecoxib. It remains to be determined whether this CV toxicity is specific to coxibs, or shared with all non-steroidal anti-inflammatory drugs (NSAID). Seven meta-analyses show that, in comparison with non-specific NSAIDs, the risk of thrombotic CV accident is increased with rofecoxib and celecoxib, but not with valdecoxib or lumiracoxib. Concerning the risk of thrombotic CV accident, seven of the ten observational studies which have evaluated the risk, have found an increased risk for the non-specific NSAID in comparison with non-exposed subjects,. The seven observational studies, which evaluated the risk of coxibs, have all found an increased risk with rofecoxib, and two with celecoxib. Three studies out of six have shown an increase of risk with rofecoxib and one study out of five with celecoxib. Two of the three studies, which have compared rofecoxib with celecoxib, have found an increased risk with rofecoxib. Concerning the risk of arterial hypertension, oedemas or congestive cardiac insufficiency, a meta-analysis and a randomised trial have shown a deleterious effect of rofecoxib in comparison with celecoxib and non-specific NSAID. Two studies have shown a deleterious effect of the non-selective NSAID and three a deleterious effect of rofecoxib in comparison with non-exposed subjects. Three studies have demonstrated a deleterious effect of rofecoxib in comparison with non-specific NSAID. No study has shown any deleterious effect of celecoxib in comparison with subjects non-exposed or exposed to non-specific NSAID. These studies suggest that all the NSAID, specific or not, increase the CV and renal risk. This risk seems variable from a compound to another one and must be evaluated, for each patient, according to the susceptibility and associated risk factors. While waiting for other long-term controlled studies, the available data show the existence of a risk of CV secondary effect linked to the class of NSAID, specific (coxibs) or not.

Review of the cardiovascular safety of COXIBs compared to NSAIDS

There is no doubt that NSAIDs and COXIBS are the mainstay for managing pain and inflammation in arthritis. Overall, at therapeutically equivalent doses, both NSAIDs and COXIBs provide equivalent analgesic and anti-inflammatory efficacy. However, the gastrointestinal risk associated with NSAIDs is considerable. More recently, the cardiovascular risk associated with NSAIDs and COXIBs has become a concern. Most patients, particularly the young, can benefit from NSAIDs without the risk of serious adverse gastrointestinal or cardiovascular events. However, patients with a previous history of serious gastrointestinal complications and the elderly, who could be at risk, do require alternatives. COXIBs have significant benefits over NSAIDs in reducing the incidence of serious gastrointestinal complications (perforations, ulcers and gastric bleeding). Currently two oral COXIBs are available, celecoxib and lumiracoxib, and one parenteral COXIB, parecoxib. Celecoxib has been on the market for longer and has the largest body of evidence. The older NSAIDs, such as meloxicam, with preferential COX-2 inhibition do not have good long-term evidence of reducing the incidence of serious gastrointestinal complications. However, these agents do have evidence of tolerability, ie, reducing the less-serious gastrointestinal effects, mainly dyspepsia. The South African Rheumatoid Arthritis Association's guidelines, amended in November 2005 recommend COXIBs for elderly patients (> 60 years) with previous gastropathy and those on warfarin and/or corticosteroids, providing they do not have contra-indications. However, caution is advised when prescribing COXIBs for patients with risk factors for heart disease. These recommendations are very similar to those made by the National Institute for Clinical Excellence (NICE). In addition, it should be noted that for those patients without any cardiovascular complications but with gastrointestinal risk factors or on aspirin, it may be necessary to add a proton pump inhibitor (PPI). PPIs, however, provide little benefit for bleeding and ulceration of the lower intestine. One consequence of this low-grade bleeding is anaemia and a general feeling of malaise in patients with rheumatic disease. Current evidence suggests that COXIBs such as rofecoxib and celecoxib do not increase small intestinal permeability and that celecoxib does not cause lower intestinal bleeding and may be of benefit to those patients with lower gastrointestinal complications. In patients at risk for cardiovascular complications, both NSAIDs and COXIBs have been shown to increase the risk of myocardial infarctions (MI), hypertension and heart failure. Studies comparing COXIBs and non-specific NSAIDs should, however, be interpreted with caution. One needs to take into account the underlying baseline cardiovascular risk of the populations being compared. COXIBs appear to be prescribed preferentially to patients who were at an increased risk of cardiovascular events compared with patients prescribed non-specific NSAIDs. When the overall risk of cardiovascular complications is relatively low and an anti-inflammatory agent is required, current evidence suggests that celecoxib is an agent of choice because of its lower cardiovascular toxicity potential compared to NSAIDs and other COXIBs.

Evidence-based recommendations for the management of ankylosing spondylitis: systematic literature search of the 3E Initiative in Rheumatology involving a broad panel of experts and practising rheumatologists

OBJECTIVE

Recommendations and/or guidelines represent a popular way of integrating evidence-based medicine into clinical practice. The 3E Initiatives is a multi-national effort to develop recommendations for the management of rheumatic diseases, which involves a large number of experts combined with practising rheumatologists addressing specific questions relevant to clinical practice.

METHODS

Ten countries participated in three rounds of discussions and votes concerning the management of AS. A set of nine questions was formulated in the domains of diagnosis, monitoring and treatment, after a Delphi procedure. A literature search in MedLine was conducted. Predefined outcome parameters for the domains of diagnosis, monitoring and treatment were assessed. The evidence to support each proposition was evaluated and scored. After discussion and votes, the final recommendations were presented using brief statements by each national group, following which the final international recommendations were formulated.

RESULTS

A total of 2699 papers were found and 467 were selected for analysis. Twelve key recommendations were developed: three in the domain of diagnosis addressing general diagnostic considerations, early AS diagnosis and general practitioners' referral recommendations; three concerning monitoring of AS disease activity, severity and prognosis; six concerning pharmacological treatment (except biologics): non-steroidal anti-inflammatory drugs/COX-II inhibitors, bisphosphonates and treatment of enthesitis. The compiled agreement among experts ranged from 72% to 93%.

CONCLUSION

Recommendations for the management of AS were developed using an evidence-based approach followed by expert/physician consensus with high level of agreement. Involvement of a larger and more representative group of rheumatologists may improve their dissemination and implementation in daily clinical practice.

Endoscopic ulcer rates in healthy subjects associated with use of aspirin (81 mg q.d.) alone or coadministered with celecoxib or naproxen: a randomized, 1-week trial

AIM

To determine the rate of endoscopic gastric/duodenal ulcers (GDUs) associated with use of aspirin (81 mg q.d.) alone or coadministered with celecoxib or naproxen.

METHODS

In this multicenter, double-blind study, healthy subjects were randomized to receive daily aspirin (81 mg q.d.) plus celecoxib 200 mg q.d., naproxen 500 mg b.i.d., or placebo. Upper endoscopy was performed at baseline and day 7. The primary end point was incidence of GDUs >or=3 mm diameter.

RESULTS

Incidence of GDUs was significantly lower in subjects receiving celecoxib plus aspirin (7%) compared with naproxen plus aspirin (25.3%; relative risk [RR], 0.28 [95% confidence interval (CI), 0.17-0.45]; P < 0.001), but significantly higher than placebo plus aspirin (1.6%; RR, 4.78 [95% CI, 1.12-20.32]; P = 0.016).

CONCLUSION

In a healthy population taking aspirin (81 mg q.d.), coadministration of celecoxib resulted in fewer GDUs than naproxen, but significantly more mucosal damage than aspirin alone.

Cardiovascular risk, hypertension, and NSAIDs

During the past 2 years, a great deal of evaluation has been conducted on the cardiovascular (CV) effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase (COX)-2 inhibitors. This review focuses on the effects of the NSAIDs and COX-2 inhibitors on blood pressure and CV events. Clinical trial databases for NSAIDs and COX-2 inhibitors have shown varying levels of destabilization of blood pressure control in treated hypertensive patients as well as variable incident rates of the development of arrhythmias, congestive heart failure, myocardial infarction, and stroke. Nonselective and COX-2 selective NSAIDs can be used carefully in arthritis patients with hypertension and stable CV disorders (excluding congestive heart failure and moderate to severe kidney dysfunction) when the individual clinical benefit of anti-inflammatory therapy outweighs the CV and gastrointestinal risk.

The David Y. Graham lecture: use of nonsteroidal antiinflammatory drugs in a COX-2 restricted environment

Recent evidence suggests that both cyclooxygenase-2 (COX-2) inhibitors and nonselective NSAIDs, with the possible exception of naproxen, increase cardiovascular (CV) hazard. Clinicians should assess not only patients' GI risk but also their CV risk before prescribing these drugs. Patients with low CV risk can be managed according to their GI risk-low-risk patients (without risk factors) receive nonselective NSAIDs, medium risk patients (1-2 risk factors) receive COX-2 inhibitors or nonselective NSAIDs plus a proton pump inhibitor (PPI) or misoprostol, whereas high-risk patients (multiple risk factors, previous ulcer complications, or concomitant anticoagulants) receive a COX-2 inhibitor plus a PPI or misoprostol. Among patients with high CV risk (e.g., prior cardiothrombotic events) who require NSAIDs, naproxen is preferred. These patients should receive a prophylactic PPI or misoprostol because the risk of ulcer bleeding is substantially increased with concomitant use of naproxen and low-dose aspirin. Substitution of clopidogrel for aspirin is not recommended in patients at risk for upper GI bleeding who require antiplatelet therapy. Patients with high GI and high CV risk should avoid NSAIDs and COX-2 inhibitors. If antiinflammatory analgesics are required, the choice of therapy depends on the relative importance of GI and CV risks of individual patients. Combination of naproxen, low-dose aspirin, and a PPI or misoprostol is recommended if CV risk is the major concern (e.g., recent myocardial infarction). In contrast, combination of low-dose COX-2 inhibitor, low-dose aspirin, and a PPI or misoprostol is preferred if GI risk outweighs CV risk (e.g., recent ulcer bleeding and stable CV disease).

Are COX-2 inhibitors preferable to non-selective non-steroidal anti-inflammatory drugs in patients with risk of cardiovascular events taking low-dose aspirin?

Cyclo-oxygenase-2 selective inhibitors and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) are associated with increased risk of acute cardiovascular events. Only aspirin offers primary and secondary cardiovascular prophylaxis, but trials have not answered directly whether low-dose aspirin is cardioprotective with COX-2 inhibitors. A large inception cohort study showed that concomitant use of aspirin reduced risk of cardiovascular events when given with rofecoxib, celecoxib, sulindac, meloxicam, and indometacin but not when given with ibuprofen. In large trials assessing gastrointestinal safety, there were fewer gastrointestinal events in patients using both COX-2 inhibitors and aspirin than in those using non-selective NSAIDs and aspirin; significantly fewer uncomplicated upper gastrointestinal events took place in the MEDAL trial. Analysis of VIGOR and two capsule endoscopy studies showed significantly less distal gastrointestinal blood loss with COX-2 inhibitors than with non-selective NSAIDs. Endoscopy trials showed that low-dose aspirin does not diminish the gastrointestinal benefits of COX-2 inibitors over non-selective NSAIDs. In an elderly epidemiological cohort receiving aspirin, both celecoxib and rofecoxib reduced risk of admission for gastrointestinal events. Comparison of the cardiovascular and gastrointestinal risks is difficult: likelihood and severity of cardiovascular events differ between individuals, agents, and exposure. Mortality associated with gastrointestinal events is less frequent than with cardiovascular events, but asymptomatic ulcers can result in severe complications. Data support the conclusion that COX-2 inhibitors are preferable to non-selective NSAIDs in patients with chronic pain and cardiovascular risk needing low-dose aspirin, but relative risks and benefits should be assessed individually for each patient.

Cardiovascular thromboembolic adverse effects associated with cyclooxygenase-2 selective inhibitors and nonselective antiinflammatory drugs

BACKGROUND

Concerns of increased cardiovascular (CV) thromboembolic adverse effects from nonsteroidal antiinflammatory drugs (NSAIDs, both nonselective [NS]-NSAIDs and cyclooxygenase [COX]-2 selective inhibitors) have prevented their use despite numerous benefits.

METHODS

In this descriptive review, we critically examine the randomized, active- and placebo-controlled studies, observational trials, and meta-analyses evaluating the CV adverse effects associated with long-term and short-term use of COX-2 selective inhibitors and NS-NSAIDs. The potential mechanisms for these CV effects are also presented.

RESULTS

Although the studies evaluating the CV risks have limitations, there appears to be an increased CV risk with both COX-2 selective inhibitors and NS-NSAIDs, particularly in high-risk patients. Therefore, the United States Food and Drug Administration has given a similar "boxed" warning highlighting the potential for increased risk of CV events associated with their use. Nevertheless, there are differences in the CV risks between COX-2 selective inhibitors (e.g., higher CV risk with rofecoxib than celecoxib) as well as differences in the CV risks between individual NS-NSAIDs (e.g., higher CV risks with diclofenac than naproxen).

CONCLUSIONS

Until long-term, prospective, randomized, adequately powered, clinical studies in relevant patient populations have been completed, the CV risks associated with the use of NSAIDs, especially in high-risk patients, will likely continue to be controversial. Nevertheless, the benefits of their short-term (e.g., perioperative) use in patients without CV risks probably outweigh their potential CV adverse effects. Finally, careful risk/benefit assessment should be undertaken and both COX-2 selective inhibitors and NS-NSAIDs should be used with caution in patients with CV risk factors.

Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain

OBJECTIVE

To conduct an economic evaluation of the Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) program.

METHODS

Alongside a clinical trial, we estimated the costs of usual primary care and participation in ESCAPE-knee pain delivered to individuals (Indiv-rehab) or groups of 8 participants (Grp-rehab). Information on resource use and informal care received was collected during face-to-face interviews. Cost-effectiveness and cost-utility were assessed from between-group differences in costs, function (primary clinical outcome), and quality-adjusted life years (QALYs). Cost-effectiveness acceptability curves were constructed to represent uncertainty around cost-effectiveness.

RESULTS

Rehabilitation (regardless of whether Indiv-rehab or Grp-rehab) cost 224 pounds (95% confidence interval [95% CI] 184 pounds, 262 pounds) more per person than usual primary care. The probability of rehabilitation being more cost-effective than usual primary care was 90% if decision makers were willing to pay 1,900 pounds for improvements in functioning. Indiv-rehab cost 314 pounds/person and Grp-rehab 125 pounds/person. Indiv-rehab cost 189 pounds (95% CI 168 pounds, 208 pounds) more per person than Grp-rehab. The probability of Indiv-rehab being more cost-effective than Grp-rehab increased as willingness to pay (WTP) increased, reaching 50% probability at WTP 5,500 pounds. The lack of differences in QALYs across the arms led to lower probabilities of cost-effectiveness based on this outcome.

CONCLUSION

Provision of ESCAPE-knee pain had small cost implications, but it was more likely to be cost-effective in improving function than usual primary care. Group rehabilitation reduces costs without compromising clinical effectiveness, increasing probability of cost-effectiveness.

Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial

OBJECTIVE

Chronic knee pain is a major cause of disability and health care expenditure, but there are concerns about efficacy, cost, and side effects associated with usual primary care. Conservative rehabilitation may offer a safe, effective, affordable alternative. We compared the effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies (Enabling Self-management and Coping with Arthritic Knee Pain through Exercise [ESCAPE-knee pain]) with usual primary care in improving functioning in persons with chronic knee pain.

METHODS

We conducted a single-blind, pragmatic, cluster randomized controlled trial. Participants age >/=50 years, reporting knee pain for >6 months, were recruited from 54 inner-city primary care practices. Primary care practices were randomized to continued usual primary care (i.e., whatever intervention a participant's primary care physician deemed appropriate), usual primary care plus the rehabilitation program delivered to individual participants, or usual primary care plus the rehabilitation program delivered to groups of 8 participants. The primary outcome was self-reported functioning (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning [WOMAC-func]) 6 months after completing rehabilitation.

RESULTS

A total of 418 participants were recruited; 76 (18%) withdrew, only 5 (1%) due to adverse events. Rehabilitated participants had better functioning than participants continuing usual primary care (-3.33 difference in WOMAC-func score; 95% confidence interval [95% CI] -5.88, -0.78; P = 0.01). Improvements were similar whether participants received individual rehabilitation (-3.53; 95% CI -6.52, -0.55) or group rehabilitation (-3.16; 95% CI -6.55, -0.12).

CONCLUSION

ESCAPE-knee pain provides a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants.

Drug insight: cyclo-oxygenase-2 inhibitors--a critical appraisal

Following the withdrawal of rofecoxib and valdecoxib, the discussion concerning selective cyclo-oxygenase (COX)-2 inhibitors was often characterized more by emotions than scientific evidence. In fact, the original rationale of these substances is still valid, in that selective COX2 inhibitors cause significantly fewer severe side effects in the gastrointestinal tract than traditional NSAIDs. Off-label long-term use of COX2 inhibitors in patients with a history of colorectal adenomas in well-designed, placebo-controlled trials showed that treatment with these agents is associated with an increased rate of cardiovascular adverse effects. Other studies have shown that both COX2 inhibitors and NSAIDs are associated with a similar cardiovascular risk, suggesting that there is presently no rationale for a further differentiation of these groups of drugs in terms of cardiovascular toxicity. Referring to the current debate, potential mechanisms underlying cardiovascular adverse effects associated with the long-term use of COX2 inhibitors and NSAIDs are discussed. Moreover, this Review summarizes the pharmacology of COX2 inhibitors with emphasis on their different pharmacokinetic characteristics.

Cardiovascular effects of cyclooxygenase-2 inhibitors

PURPOSE OF REVIEW

Arthritis and musculoskeletal disorders are highly prevalent and management often involves the use of nonsteroidal antiinflammatory drugs. Cyclooxygenase-2 enzyme inhibitors are newer selective nonsteroidal antiinflammatory drugs that purport to exhibit less gastrointestinal toxicity than traditional nonsteroidal antiinflammatory drugs. Cardiotoxicity has been an adverse outcome of cyclooxygenase-2 inhibitors and this article will critically review the evidence.

RECENT FINDINGS

Although there is less than perfect evidence, both traditional nonsteroidal antiinflammatory drugs, with the possible exception of naproxen, and cyclooxygenase-2 inhibitors are associated with increased thrombotic cardiovascular risk. There is strong evidence supporting the cardiotoxicity of rofecoxib and valdecoxib, but less compelling evidence for the other cyclooxygenase-2 inhibitors. Observational studies have been helpful in providing confirmatory and complimentary evidence about this cardiotoxicity. The thrombotic cardiovascular risk begins upon drug introduction, continues throughout exposure and is greatest in patients with a high baseline cardiac risk profile. Cyclooxygenase-2 inhibitors are also associated with other nonthrombotic cardiovascular risks.

SUMMARY

The totality of the evidence suggests that all cyclooxygenase-2 inhibitors are associated with increased cardiotoxicity. The cardiovascular risks of the different cyclooxygenase-2 inhibitors are not homogeneous, however, and are likely influenced not only by a class effect, but also by individual drug, dosage and patient characteristics.

Non-steroidal anti-inflammatory drugs and myocardial infarctions: comparative systematic review of evidence from observational studies and randomised controlled trials

OBJECTIVE

The comparative risk of myocardial infarction (MI) with cyclo-oxygenase-2-specific drugs and traditional non-steroidal anti-inflammatory drugs (NSAIDs) was determined.

METHODS

The results of studies of a suitable size in colonic adenoma and arthritis-that had been published in English and from which crude data about MIs could be extracted-were evaluated. Medline, Embase and Cinahl (2000-2006) databases, as well as published bibliographies, were used as data sources. Systematic reviews examined MI risks in case-control and cohort studies, as well as in randomised controlled trials (RCTs).

RESULTS

14 case-control studies (74 673 MI patients, 368 968 controls) showed no significant association of NSAIDs with MI in a random-effects model (OR 1.17; 95% CI 0.99 to 1.37) and a small risk of MI in a fixed-effects model (OR 1.32; 95% CI 1.29 to 1.35). Sensitivity analyses showed higher risks of MI in large European studies involving matched controls. Six cohort studies (387 983 patient years, 1 120 812 control years) showed no significant risk of MI with NSAIDs (RR 1.03; 95% CI 1.00 to 1.07); the risk was higher with rofecoxib (RR 1.25; 95% CI 1.17 to 1.34) but not with any other NSAIDs. Four RCTs of NSAIDs in colonic adenoma (6000 patients) showed an increased risk of MI (RR 2.68; 95% CI 1.43 to 5.01). Fourteen RCTs in arthritis (45 425 patients) showed more MIs with cyclo-oxygenase-2-specific drugs (Peto OR 1.6; 95% CI 1.1 to 2.4), but fewer serious upper gastrointestinal events (Peto OR 0.40; 95% CI 0.31 to 0.53).

CONCLUSION

The overall risk of MI with NSAIDs and cyclo-oxygenase-2-specific drugs was small; rofecoxib showed the highest risk. There was an increased MI risk with cyclo-oxygenase-2-specific drugs compared with NSAIDs, but less serious upper gastrointestinal toxicity.

Selective COX-2 inhibitors, NSAIDs and cardiovascular events - is celecoxib the safest choice?

Inhibitors of cyclo-oxogenase (COX) are widely used anti-inflammatory drugs. In recent years concerns have arisen about the cardiovascular safety of these drugs, initially because of reported associations between therapy with the COX-2 selective inhibitor rofecoxib and myocardial infarction. However, subsequent data have suggested an association between therapy with non-selective COX inhibitors (NSAIDs) and serious cardiovascular events. This article reviews the clinical trial and population data linking COX inhibition to cardiovascular events. The data currently available suggests that both specific and non-specific COX inhibitors may increase the risk of serious cardiovascular events, but that the effect varies between the individual drugs. The strongest evidence for an increased risk of serious cardiovascular events is with rofecoxib therapy. Celecoxib therapy may be associated with an increased risk of cardiovascular events, but only when used at doses substantially higher than those recommended for the treatment of arthritis. There is a greater body of evidence supporting the relative cardiovascular safety of celecoxib when used at the doses recommended for the treatment of arthritis than for any of the other selective COX-2 inhibitors or NSAIDs.

Association between nonnaproxen NSAIDs, COX-2 inhibitors and hospitalization for acute myocardial infarction among the elderly: a retrospective cohort study

PURPOSE

To evaluate the association between rofecoxib, celecoxib, diclofenac, and ibuprofen and the risk of hospitalization for acute myocardial infarction (AMI) in an elderly population.

METHODS

We conducted a retrospective cohort study, using data from the government of Quebec health insurance agency databases, among patients 65-80 years of age who filled a prescription for any of the study drugs during 1999-2002. Cox regression models with time-dependent exposure were used to compare the incidence rates of hospitalization for AMI adjusting for patients' baseline characteristics. Analyses stratified by dose and number of supplied days were also conducted.

RESULTS

At the index date, a total of 91 062 patients were taking rofecoxib, 127 928 celecoxib, 49 193 diclofenac, and 15 601 ibuprofen. The adjusted hazard ratio (HR) (95%CI) of hospitalization for AMI were: celecoxib versus rofecoxib: 0.90 (0.79, 1.01); ibuprofen versus rofecoxib: 0.95 (0.65, 1.37); diclofenac versus rofecoxib: 1.01 (0.84, 1.22). In secondary analyses based on intended duration of use, neither COX-2 selective inhibitor was associated with a higher risk than ibuprofen or diclofenac. The unadjusted risk of AMI for all NSAIDs increased with dose. In the direct two way adjusted comparison of each NSAID stratified by dose, the only statistically significant difference was with rofecoxib >25 mg/day versus celecoxib >200 mg/day.

CONCLUSION

In this study there was no difference between AMI occurrence in elderly patients taking rofecoxib or celecoxib at recommended doses for chronic indications versus those taking ibuprofen/diclofenac. However, the risk of AMI was higher among patients using higher doses of rofecoxib (>25 mg/day) compared to patients using higher doses of celecoxib (>200 mg/day).

The CADEUS study: methods and logistics

PURPOSE

At the request of the French Health authorities, a study called CADEUS (COX-2 inhibitors and NSAIDs: description of users) aimed to describe the users of cyclo-oxygenase (COX)-2 inhibitors and traditional non-selective non-steroidal anti-inflammatory drugs (tNSAIDs). We report here the methodology, logistics and study design performances.

METHODS

CADEUS is a cohort study designed to include 40,000 patients randomly sampled monthly in the French National Healthcare Insurance database, who received at least one dispensation of celecoxib, rofecoxib or tNSAIDs (1:1:2), from September 2003 to August 2004. Patients and prescribers were asked to fill a questionnaire on indication, medical history, risk factors and hospitalizations since drug acquisition. There was no reminder. For each respondent, healthcare resources used for the 6 months before and after inclusion were extracted from the database. Response rate, response delay, responders and non-responders characteristics were assessed.

RESULTS

Of the 222,879 patients and their prescribers contacted, 20.8% patients and 32.6% prescribers responded. Median response delay was 16 days for patients and 17 days for physicians. Factors associated with patient response were age, cohort, type of prescriber and period of inclusion.

CONCLUSION

This is the first study of this design in France, combining data from a claims database and direct patient and prescriber questionnaires.

The tell-tale heart: population-based surveillance reveals an association of rofecoxib and celecoxib with myocardial infarction

Background

COX-2 selective inhibitors are associated with myocardial infarction (MI). We sought to determine whether population health monitoring would have revealed the effect of COX-2 inhibitors on population-level patterns of MI.

Methodology/Principal Findings

We conducted a retrospective study of inpatients at two Boston hospitals, from January 1997 to March 2006. There was a population-level rise in the rate of MI that reached 52.0 MI-related hospitalizations per 100,000 (a two standard deviation exceedence) in January of 2000, eight months after the introduction of rofecoxib and one year after celecoxib. The exceedence vanished within one month of the withdrawal of rofecoxib. Trends in inpatient stay due to MI were tightly coupled to the rise and fall of prescriptions of COX-2 inhibitors, with an 18.5% increase in inpatient stays for MI when both rofecoxib and celecoxib were on the market (P<0.001). For every million prescriptions of rofecoxib and celecoxib, there was a 0.5% increase in MI (95%CI 0.1 to 0.9) explaining 50.3% of the deviance in yearly variation of MI-related hospitalizations. There was a negative association between mean age at MI and volume of prescriptions for celecoxib and rofecoxib (Spearman correlation, −0.67, P<0.05).

Conclusions/Significance

The strong relationship between prescribing and outcome time series supports a population-level impact of COX-2 inhibitors on MI incidence. Further, mean age at MI appears to have been lowered by use of these medications. Use of a population monitoring approach as an adjunct to pharmacovigilence methods might have helped confirm the suspected association, providing earlier support for the market withdrawal of rofecoxib.

High-dose ibuprofen in cystic fibrosis: Canadian safety and effectiveness trial

OBJECTIVE

To assess the effectiveness and safety of high-dose ibuprofen when used as part of routine therapy in patients with cystic fibrosis (CF).

STUDY DESIGN

In this multicenter, double-blinded, placebo-controlled trial, a total of 142 patients age 6 to 18 years with mild lung disease (forced expiratory volume in 1 minute [FEV1] > 60 predicted) were randomized to receive either high-dose ibuprofen (70 subjects, 20 to 30 mg/kg/twice daily, adjusted to a peak serum concentration of 50 to 100 mug/mL) or placebo (72 subjects) for a 2-year period. The primary outcome was the annualized rate of change in FEV1% predicted.

RESULTS

The patients in the high-dose ibuprofen group exhibited a significant reduction in the rate of decline of forced vital capacity percent predicted (0.07 +/- 0.51 vs -1.62 +/- 0.52; P = .03), but not FEV1%. The ibuprofen group also spent fewer days in hospital after adjusting for age (1.8 vs 4.1 days per year; P = .07). A total of 11 patients (4 in the ibuprofen group and 7 in the placebo group) withdrew due to adverse events.

CONCLUSIONS

High-dose ibuprofen has a significant effect on slowing the progression of lung disease in CF and generally is well tolerated.

Osteoarthritis of the knee

INTRODUCTION

Osteoarthritis of the knee affects about 10% of adults aged over 60 years, with risk increased in those with obesity, and joint damage or abnormalities. Progression of disease on x rays is commonplace, but x ray changes don't correlate well with clinical symptoms.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of non-surgical treatments for osteoarthritis of the knee? What are the effects of surgical treatments for osteoarthritis of the knee? We searched: Medline, Embase, The Cochrane Library and other important databases up to October 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 74 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, capsaicin, chondroitin, education to aid self-management, exercise and physiotherapy, glucosamine, insoles, intra-articular corticosteroids, intra-articular hyaluronan, joint bracing, knee replacement, non-steroidal anti-inflammatory drugs (including topical non-steroidal anti-inflammatory drugs), opioid analgesics, osteotomy, simple analgesics, and taping.

Lifestyle during and after cancer treatment

The aim of this overview was to examine the evidence for links between lifestyle during and after cancer treatment and quality of life, risk of treatment side-effects, rate of progression and prevention of relapse. The reviewed studies were divided into categories according to the role lifestyle plays in progression, during treatment, and in relapse prevention. The evaluated evidence was utilised to show potential lifestyle interventions to facilitate well-being and quality-of-life initiatives. There is now persuasive evidence that dietary choice and exercise can improve the physical and psychological function of patients with cancer. There is also persuasive evidence that lifestyle choice can prevent cancer or the reoccurrence of cancer in susceptible individuals, and possibly improve survival.

Risk of colorectal cancer in patients prescribed statins, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2 inhibitors: nested case-control study

BACKGROUND AND AIMS

Several studies suggest that statins prevent some cancers, with one study finding a 47% reduction in colorectal cancer risk after >or=5 years of regular use.

METHODS

A nested case-control study was conducted within 454 general practices in the United Kingdom using the QRESEARCH database. Cases with colorectal cancer were diagnosed between 1995 and 2005. The effects of statins, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, and aspirin on colorectal cancer were estimated with conditional logistic regression adjusted for morbidity, smoking status, body mass index, and socioeconomic status.

RESULTS

We analyzed 5686 cases and 24,982 matched controls with >or=4 years of records. The adjusted odds ratio for colorectal cancer associated with any statin prescription was 0.93 (95% confidence interval: 0.83-1.04), with no trend in duration of use or number of prescriptions. For any nonsteroidal anti-inflammatory drug prescription the adjusted odds ratio was 0.94 (95% confidence interval: 0.88-1.00), with a significant decrease in risk with increasing number of prescriptions and an adjusted odds ratio of 0.76 (0.60-0.95) for >or=25 prescriptions. Prolonged use of cyclooxygenase-2 inhibitors was minimal, but for those receiving >or=25 prescriptions the adjusted odds ratio was 0.34 (0.14-0.85). Results were similar in the subset of participants with >or=8 years of records; the adjusted odds ratio for >or=61 months of statin prescriptions was 1.00 (0.67-1.48).

CONCLUSIONS

In this large population-based case-control study prolonged use of nonsteroidal anti-inflammatory drug and cyclooxygenase-2 inhibitor was associated with a reduced colorectal cancer risk, but prolonged statin use was not.