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GPs and PCTs are questioning whether any marginal benefit of cox-2 inhibitors over non-selective NSAIDs is worth the added cost in the wake of further evidence casting doubt on their safety.
Pulse has learned some PCTs are already advising
GPs to favour conventional NSAIDs.
And a member of the
Primary Care Rheumatology Society has called for NICE
to carry out an urgent
economic evaluation of cox-2 inhibitors to guide GP prescribing and claimed many patients may not need NSAIDs at all.
GP rheumatology experts described the issue as 'confusing' and 'a nightmare' in the wake of two new studies finding cox-2s were no better for gastrointestinal events than non-selective NSAIDs and another claiming the risks were being overestimated (see box).
The British Society for Rheumatology admitted there was a 'quagmire of data and comment' but said critics of cox-2 inhibitors had been 'cherry-picking' the data and that evidence of reduced risk of gastrointestinal haemorrhages was 'robust'.
But Dr Steve Longworth, a GP in Leicester and past-president of the Primary Care Rheumatology Society, said the evidence was 'confused' and added: 'GPs have to ask themselves do [patients] need to go on an anti-inflammatory at all when there are paracetamol or non-pharmacological interventions available.'
There appears to be substantial variation between PCTs in prescribing policy.
Redbridge PCT said it was likely to suggest there was little difference between cox-2 inhibitors and conventional NSAIDs while Bath and North-East Somerset PCT planned to recommend a non-selective NSAID with proton pump inhibitor instead.
But North-East Lincoln-shire PCT said its policy would be to reinforce NICE guidance and wait for the review.
Broadlands PCT said there was a feeling cox-2 inhibitors were not being used in line with guidelines.
Cox-2 inhibitors – the latest evidence
•Cox-2 use associated with more serious GI
events than either diclofenac or ibuprofen
(recent data from the International Society for Pharmaco-Epidemiology conference)
•Ulcers more common in patients taking rofecoxib plus aspirin than with placebo or aspirin alone – Gastroenterology (August)
•Cox-2s were 'selectively' prescribed to at-risk patients – overestimating their risk
(also from the ISPE conference)
By Rob Finch