Experience of rofecoxib in patients with osteoarthritis previously treated with traditional non-steroidal anti-inflammatory drugs in Spain: results of phase 2 of the VICOXX study

Clinician reported ease of use for a novel fibrin sealant patch for hemostasis: results from four randomized controlled trials

BACKGROUND

In addition to rapid and sustained efficacy, ease of use is also an important characteristic of topical hemostats.

OBJECTIVES

To evaluate clinician-reported ease of use for the Evarrest fibrin sealant patch across various surgical bleeding situations.

METHODS

An ease of use questionnaire (EUQ) was validated and administered in four randomized studies comparing the fibrin sealant patch to standard of care (SoC) in soft tissue and hepatic surgical bleeding. Three of these randomized studies have been previously published and all have been registered (NCT00658723; NCT00977925; NCT01166243; NCT01993888). The EUQ is a 19 item instrument evaluating clinician's preferences on five subscales: product ease of use, satisfaction with product properties and efficiency, confidence in product efficacy, global confidence, and global satisfaction. A pair-wise meta-analysis using a random effects model was conducted on EUQ scores for trials that reported data for both treatment arms. Individual scores are presented for each trial.

RESULTS

The fibrin sealant patch demonstrated numerically greater scores than SoC in all EUQ subscales. The meta-analysis demonstrated that fibrin sealant patch scores improved for all subscales compared with SoC: satisfaction with product properties (mean difference [MD] = 0.38, 95% CI: 0.04 to 0.73; P = 0.03), confidence in efficacy (MD = 1.10, 95% CI: 0.47 to 1.74; P = 0.0007), global confidence (MD = 0.57, 95% CI: 0.05 to 1.10, P = 0.03), global satisfaction (MD = 0.79, 95% CI: 0.32 to 1.26, P = 0.001), and ease of use (MD = 0.33, 95% CI: -0.29 to 0.94; P = 0.23). Fibrin sealant patch single arm trial results aligned with these findings.

CONCLUSIONS

Physicians consistently reported high EUQ scores for the fibrin sealant patch across surgical bleeding populations. An important limitation of this study was that the composition of SoC varied across studies and EUQ data were only available for the SoC in two of four trials. Future studies should evaluate ease of use for other hemostats and across other surgical subspecialties, as data are currently limited.

Tolerability and adverse events in clinical trials of celecoxib in osteoarthritis and rheumatoid arthritis: systematic review and meta-analysis of information from company clinical trial reports

The objective was to improve understanding of adverse events occurring with celecoxib in the treatment of osteoarthritis and rheumatoid arthritis. Data were extracted from company clinical trial reports of randomised trials of celecoxib in osteoarthritis or rheumatoid arthritis lasting 2 weeks or more. Outcomes were discontinuations (all cause, lack of efficacy, adverse event, gastrointestinal adverse event), endoscopically detected ulcers, gastrointestinal or cardio-renal events, and major changes in haematological parameters. The main comparisons were celecoxib (all doses) versus placebo, paracetamol (acetaminophen) 4,000 mg daily, rofecoxib 25 mg daily, or nonsteroidal anti-inflammatory drugs (NSAIDs) (naproxen, diclofenac, ibuprofen, and loxoprofen). For NSAIDs, celecoxib was compared both at all doses and at licensed doses (200 to 400 mg daily). Thirty-one trials included 39,605 randomised patients. Most patients had osteoarthritis and were women of average age 60 years or above. Most trials lasted 12 weeks or more. Doses of celecoxib were 50 to 800 mg/day. Compared with placebo, celecoxib had fewer discontinuations for any cause or for lack of efficacy, fewer serious adverse events, and less nausea. It had more patients with dyspepsia, diarrhoea, oedema, more adverse events that were gastrointestinal or treatment related, and more patients experiencing an adverse event. There were no differences for hypertension, gastrointestinal tolerability, or discontinuations for adverse events. Compared with paracetamol, celecoxib had fewer discontinuations for any cause, for lack of efficacy, or diarrhoea, but no other differences. Compared with rofecoxib, celecoxib had fewer patients with abdominal pain and oedema, but no other differences. Compared with NSAIDs, celecoxib had fewer symptomatic ulcers and bleeds, endoscopically detected ulcers, and discontinuations for adverse events or gastrointestinal adverse events. Fewer patients had any, or a gastrointestinal, or a treatment-related adverse event, or vomiting, abdominal pain, dyspepsia, or reduced haemoglobin or haematocrit. Discontinuations for lack of efficacy were higher. No differences were found for all-cause discontinuations, serious adverse events, hypertension, diarrhoea, nausea, oedema, myocardial infarction, cardiac failure, or raised creatinine. Company clinical trial reports present much more information than published papers. Adverse event information is clearly presented in company clinical trial reports, which are an ideal source of information for systematic review and meta-analysis.

Adverse oral reactions associated with the COX-2 inhibitor rofecoxib

Rofecoxib is an inhibitor of the enzyme cyclo-oxygenase 2 (COX-2) used as an analgesic and anti-inflammatory agent especially in rheumatoid arthritis and osteoarthritis. The adverse effects are generally less than with other anti-inflammatory drugs (NSAIDs), and no oral adverse reactions have been reported in the literature. We present three cases of oral lesions caused by rofecoxib. Extensive erosions appeared, which in all cases resolved on withdrawal of the drug.

Benefit-risk assessment of rofecoxib in the treatment of osteoarthritis

NSAIDs are widely used to treat pain and inflammation in osteoarthritis. Their use in this indication is generally intermittent and fluctuates with the intensity of the disease. Nonetheless, success of the therapy is frequently limited by injury to the gastrointestinal mucosa and complications such as bleeding, ulceration and perforation. A careful and detailed evaluation of these aspects in regard to the newly introduced NSAIDs is of considerable clinical importance. This review focuses on the NSAID rofecoxib, one of the selective cyclo-oxygenase (COX)-2 inhibitors, which are claimed to be as effective as nonselective NSAIDs with better gastrointestinal tolerability. Indeed, phase II, phase III and epidemiological studies have revealed that the efficacy of rofecoxib is comparable to that of conventional NSAIDs but with lower gastrointestinal toxicity, although this advantage may not be demonstrable in every patient. In patients treated with low-dose aspirin (acetylsalicylic acid) for cardiovascular prophylaxis, celecoxib (another selective COX-2 inhibitor) seems to have no obvious advantages over conventional NSAIDs, and similar conclusions may be applied to rofecoxib. A comparison of NSAID therapy +/- concomitant low-dose aspirin was not a primary outcome in this trial with celecoxib and there is thus a need for further studies which compare the gastrointestinal risk of a selective COX-2 inhibitor plus aspirin versus a conventional NSAID. Recent debate has emerged regarding the cardiovascular safety of rofecoxib. Although there is evidence both for and against higher cardiovascular risk with rofecoxib, a retrospective cohort study recently published suggested that there is no increased risk of acute myocardial infarction in the short-term when compared with non-selective NSAIDs. The renal toxicity of rofecoxib has been thoroughly investigated. Clinical studies revealed renal effects of rofecoxib similar to those of conventional NSAIDs. Since adverse effects increase with the degree of renal impairment, monitoring of renal function should be carried out in patients at risk. Although there are still insufficient data concerning certain important adverse effects of rofecoxib, this drug is becoming an important alternative in the therapy of osteoarthritis, especially in high-risk patients. Clinicians need to weigh up the benefits and risks of rofecoxib on a case-by-base basis.

Management pattern for patients with osteoarthritis treated with traditional non-steroidal anti-inflammatory drugs in Spain prior to introduction of Coxibs

OBJECTIVE

To investigate the use of traditional non-steroidal anti-inflammatory drugs (tNSAIDs) in the management of osteoarthritis (OA) in primary care in Spain and to quantify patient and physician satisfaction with tNSAID therapy.

METHODS

A 6-month retrospective, observational study conducted in 29 Spanish primary-care centres shortly before the first introduction of selective COX-2 inhibitors (Coxibs).

RESULTS

A total of 897 patients with a mean age 66 +/- 9 years and radiologically documented OA were included: most (76%) were women. Three-quarters of the patients had primary generalised OA, with the knees (> 60% of cases) and lumbar spine (> 50% of cases) being the sites most commonly affected. Pain was an almost universal feature of the clinical presentation. More than 96% of patients had been prescribed tNSAIDs during the observation period, predominantly for pain relief. The most commonly prescribed agents were diclofenac, aceclofenac and piroxicam. Twenty-six per cent of discontinuations of tNSAIDs during the observation period were due to limited effectiveness of these drugs, making this the largest single cause of discontinuation apart from prescription expiry. Almost half of patients and physicians (46% in both categories) were not satisfied with OA treatment and only one patient in six regarded their overall health status during tNSAID therapy as satisfactory. Gastroprotective medications (GPMs) were prescribed for just over half the participating patients (51%), but use of these drugs appeared haphazard: 25% of those who received GPMs had no compelling indications for this therapy whereas more than half of the patients at high risk for gastrointestinal complications on the basis of clinical criteria were not receiving GPMs.

CONCLUSIONS

There is a high level of dissatisfaction with tNSAID therapy of OA, arising in large part from a perception among many patients and physicians that these drugs are not always adequately effective in relieving the symptoms of this disease. These findings, together with the low patient perceptions of general health, indicate the need for new therapeutic approaches to OA.