A Recent Medical Study Calls for Minimizing Gastrointestinal Damage While Treating Arthritis

Jan. 15, 2013 - PRLog -- Patients receiving a non-selective non-steroidal anti-inflammatory drug (NSAID) plus a proton pump inhibitor (PPI)—to reduce inflammation and pain in arthritis—are more than four times more likely to suffer upper or lower gastrointestinal adverse clinical outcomes than those who receive a cyclo-oxygenase (COX)-2 selective NSAID. The findings of the CONDOR study, reported by Lancet, should encourage review of approaches to reduce risk of NSAID treatment. The study is written by Professor Francis K L Chan, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong Special Administrative Region, China, and Professor Jay Goldstein, University of Illinois at Chicago, IL, USA, and colleagues. The study is being presented at the European League Against Rheumatism (EULAR) Annual Conference in Rome.

Other studies have shown that COX-2-selective NSAIDs and non-selective NSAIDs plus a proton-pump inhibitor (PPI) have similar side effects in the upper gastrointestinal tract, but adverse effects in the entire gastrointestinal tract (including the lower part) might be less frequent with selective drugs than with non-selective drugs. This is because acid suppression does not prevent damage to the lower gastrointestinal tract.  In this study, the authors aimed to compare risk of gastrointestinal events associated with celecoxib (COX-2 selective NSAID) versus diclofenac slow release (a non-selective NSAID) plus omeprazole (a PPI).

The CONDOR study recruited patients with osteoarthritis or rheumatoid arthritis at increased gastrointestinal risk, ie, aged 60 years or over, or 18 years and older with previous gastrointestinal ulceration. The study included 196 centres in 32 countries or territories. Patients tested negative for Helicobacter pylori (a risk factor for peptic ulcer). Patients were assigned in a 1:1 ratio to receive celecoxib 200 mg twice a day or diclofenac slow release 75 mg twice a day plus omeprazole 20 mg once a day. Patients and investigators were masked to treatment allocation. The primary endpoint was a composite of clinically significant upper or lower gastrointestinal events adjudicated by an independent committee. A total of 4484 patients were randomly allocated to treatment (2238 celecoxib; 2246 diclofenac plus omeprazole) and were included in intention-to-treat analyses.

The authors conclude: “Since guidelines recommend that selection of NSAID therapy be driven by consideration of both cardiovascular and gastrointestinal effects of treatment, CONDOR has provided new data relevant to patients requiring anti-inflammatory therapy who are at increased gastrointestinal but not increased cardiovascular risk. In this population, the gastrointestinal outcomes of a COX-2 selective NSAID were quite different to those of a non-selective NSAID plus a PPI. The findings of the CONDOR trial should encourage guideline committees to review their treatment recommendations for arthritis patients.”

In an accompanying Comment, Dr Elham Rahme and Dr Sasha Bernatsky, McGill University, Montreal, QC, Canada, say: “Chan and colleagues suggest that risk of lower gastrointestinal bleeding could be as important a consideration as is risk of upper gastrointestinal bleeding.”