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Practices hit at PCO threats over referral

GPs have been thrown into confusion by the chaotic withdrawal of rofecoxib (Vioxx) with conflicting advice about how to manage patients who were on the drug.

The Department of Health has said only that the most appropriate alternative medication would 'vary from patient to patient' as experts disagree over whether patients should be switched to another cox-2 inhibitor.

EU drug watchdog the EMEA last week announced it was urgently reviewing long-term data on the cardiovascular safety of all cox-2s and would report by October 20. The UK's Medicines and Healthcare Products Regulatory Agency said it was continuing to monitor the situation through yellow card reports but did not regard cardiovascular risk as a class effect of cox-2s.

GPs are furious at the department's failure to offer guidance and the breakdown of the cascade system for distributing information. Sur-geries have been swamped by worried patients with some GPs reporting the first they heard of the drug's withdrawal was during consultations.

GP experts have offered contrasting advice on how to manage patients on rofecoxib. Some recommend a switch to another cox-2 inhibitor and others prefer a conventional NSAID and proton pump inhibitor (see below).

The lack of clarity added to the chaos after medical defence bodies urged GPs to call in patients urgently and ignore MHRA advice to wait for patients to come forward.

Dr Jim Beatson, a GP in Troon, Ayrshire, said: 'At present cascades are not working to our advantage or satisfaction. GPs as usual are piggy in the middle between patient anxiety, NHS mismanagement and total disregard by the pharmaceutical industry.'

Dr Steve Longworth, a GP in Leicester and past-president of the Primary Care Rheumatology Society, said: 'The simple fact is that people are worried and are ringing in now and if we don't get advice we have to make ad-hoc decisions.'

·Correction In last week's issue we erroneously reported findings suggesting users of celecoxib were 1.7 times more likely than non-users to suffer a cardiovascular event.

The increased risk in question was associated with use of rofecoxib and the results appeared in Ray et al (Lancet 2002;360:1071-3), not the CLASS trial as stated. CLASS found no increased cardiovascular risk with celecoxib. We apologise for the error.

What should patients be switched to?

Dr Graham Davenport Primary Care Rheumatology Society

'I would advise patients to change to the one with the best safety profile and the most data and that's celecoxib'

Dr Chaand Nagpaul GPC prescribing sub-committee

'Some GPs, like me, are taking the safe option and prescribing a PPI as a gastroprotectant with an NSAID ­ I think a lot of GPs will err on the side of caution'

Professor Tony Avery chair of the UK Drug

Utilisation Research Group

'We are asking patients to come in for a prescription review and then asking if they need to be on an NSAID at all. If so, are they at sufficiently high risk of gastrointenstinal events to need to be on a cox-2'

By Rob Finch

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