Reply to the letter regarding “Comparison of gastrointestinal adverse effects between cyclooxygenase-2 inhibitors and non-selective, non-steroidal anti-inflammatory drugs plus proton pump inhibitors: a systematic review and meta-analysis”

Abstract

To the Editor:We thank Dr. Lai and his colleagues for their commentsrelated to our article ‘‘Comparison of gastrointestinaladverse effects between cyclooxygenase-2(COX-2) inhib-itors and non-selective, non-steroidal anti-inflammatorydrugs (ns-NSAID) plus proton pump inhibitors (PPI)’’ [1].According to our analyses, the risk of major gastrointesti-nal (GI) complications was lower in COX-2 inhibitors, ascompared to ns-NSAIDs plus PPI. We agree that patientswho take COX-2 inhibitors are still at risk for GI adverseevents, when compared to patients who do not take thesemedications. As shown in a metaanalysis by Rostrom et al.[2], high-dose COX-2 inhibitors insignificantly increasedthe risk of gastric (relative risk or RR 1.22; 95% CI0.83–1.80) and duodenal (RR, 1.29; 95% CI 0.63–2.66)ulcers, as compared to placebo. However, when comparedto ns-NSAIDs, the risk of major GI complications includ-ing perforation, ulceration, bleeding, and obstruction werelower in COX-2 inhibitors.The increased risk of peptic ulcer in a cohort studyneeds to be cautiously interpreted because this study designis susceptible to selection bias resulting in imbalancedprognostic characteristics at baseline. In daily practice,physicians usually prescribe COX-2 inhibitors for patientswho are at high risk of developing GI complications, e.g.,old age, prior GI ulcer or bleeding, aspirin or anti-coagu-lant user, and steroid use, whereas patients with low riskare usually treated with ns-NSAIDs. Therefore, the risk ofGI complications between COX-2 inhibitors vs. ns-NSA-IDs may be comparable or even higher in COX-2inhibitors.We totally agree that COX-2 inhibitors are associatedwith increased risk of GI complication. Patients requiringNSAID therapy who are at high risk should receive COX-2inhibitor and GI protective therapy (e.g., misoprostol orPPI) or alternative therapy for pain control.Reference