Which anti-inflammatory drug can be used instead of Citodon in a patient with osteoarthritis and ca

Fråga: Which anti-inflammatory drug can be used instead of Citodon in a patient with osteoarthritis and cardiac insufficiency? What about a COX-2 inhibitor?

The question concerns a 63-year-old man treated with Citodon (codeine + paracetamol) 4 tablets daily for bilateral knee arthritis. A switch to Vioxx (rofecoxib) or Celebra (celecoxib) is considered. The patient has several other ailments including chronic lung obstructive disease, cardiac insufficiency and prostate cancer. Other medications include Salures K (bendroflumethiazide + potassium chloride), Triatec (ramipril), Trombyl (acetylsalicylic acid), Imdur (isosorbide-5-mononitrate), Bricanyl (terbutalin), Pulmicort (budesonide), acetylcysteine, Nitromex (nitroglyceryl) and Inolaxol.

Sammanfattning: If the goal of treatment is to relieve pain, the patient´s current treatment with Citodon seems rational and should be continued. Generally, the use of NSAIDs including COX-2 inhibitors should not be used in a patient with cardiac insufficiency and possibly with renal dysfunction. If the patient however needs an NSAID treatment, a local treatment might be tried.

Svar: In the maintenance treatment of osteoarthritis when the goal of therapy is only to reduce pain, it is well established today that the first drug of choice is paracetamol alone or in combination with a mild opioid analgesic such as codeine, dextropropoxyphene or tramadol in patients with increased pain (1). Non-steroidal anti-inflammatory drugs (NSAIDs) are indicated only in situations where inflammatory episodes take place and analgesics prove insufficient to reduce the pain and improve joint function (1). NSAIDs (including COX-2 inhibitors) are generally unsuitable or contraindicated in patients with cardiac insufficiency or with pre-existing renal disease (2). If the use of an NSAID is however warranted a "renal sparring drug" such as sulindac may be preferred in such patients. However since Sulindac is an NSAID and the risk of an acute renal failure cannot be completely ruled out, certain caution and timely monitoring of such patients is needed (3).

Rofecoxib and celecoxib have similar efficacy as traditional NSAIDs in relieving pain and improving functional status in patients with osteo- and rheumatoid arthritis (4,5). Their major advantage over traditional NSAIDs is the lower incidence of upper gastrointestinal ulcerations and complications reported in clinical trials (4,5). However, experience with these drugs is still limited particularly in high-risk groups. The number of patients included in those studies is also small and the follow-up period short (maximum one year). Thus, if this patient has no present or past history of peptic ulcer, COX-2 inhibitors do not have any documented advantage over traditional NSAIDs (6,7).

COX-2 inhibitors share with traditional NSAIDs the toxicity to the kidneys. According to the manufacturer´s latest periodic safety update of rofecoxib covering 19990801 to 20000131, 56 cases of kidney failure were registered from a population of 773000 people who used the drug (8). In Sweden, since the launching of rofecoxib one year ago, the Medical Products Agency received 7 cases of serious acute kidney function abnormalities consisting of 3 women and 4 men, between the ages of 63 and 92 years. All had received recommended doses of rofecoxib (12.5-25 mg/day). Two patients died in connection with the reaction but the remaining patients recovered after discontinuation of the drug (8). In this patient it is essential to check the renal function. Significant dysfunction speaks strongly against the use of NSAIDs including COX-2 inhibitors. The severity of cardiac insufficiency is also an important factor in influencing the decision to use NSAIDs or not.