So, what if COX-2′s are withdrawn from the market? There are plenty of patients (i.e. those with arthritis) who require an anti-inflammatory in the face of prior ulcers or GI bleeds. That is presumably why they were on Vioxx, Celebrex or Bextra in the first place.
One option would be to use COX-2 preferential medications, such as Relafen, Lodine or Mobic – all discussed previously.
If that cannot be done, then a combination of a non-selective NSAID (i.e. ibuprofen, naprosyn etc.) in combination with a GI-protective agent should be considered. I will consider two scenarios.
Those at high risk for GI bleeding
The FDA has approved two medications for high-risk GI patients who take non-selective NSAIDs: lansoprazole (Prevacid) at 15mg or 30mg daily, and misoprostol at 200ug four times daily. Thus, either of these options should be used in conjunction with the NSAID.
H Pylori should be tested for and treated if present.
Those with a prior history of GI bleeding
In patients with a history of ulcers, studies have shown that treatment with a proton-pump inhibitor (PPIs – either omeprazole at 20mg daily or lansoprazole at 15mg or 30mg daily), in conjunction with continuous NSAID use, demonstrated appropriate healing. PPIs also have been shown to be superior than other medications such as misoprostol and sucralfate in those with a prior ulcer or bleed.
Again, H Pylori should be tested for and treated if present.
Bottom line
If Celebrex and the other COX-2′s are pulled in the near future, here are the options you want to discuss with your physician:
1) Switch to Tylenol.
2) Switch to Lodine, Mobic, or Relafen which are COX-2 preferential; or,
3) Switch to a non-selective NSAID, i) in combination with a PPI or misoprostol if you are at high risk for GI bleeding, or ii) in combination with a PPI if you have a history of GI bleeding.
