The safety debate on cyclooxygenase-2 inhibitors stirs public hysteria for several reasons ("New Data Fail to Resolve the Issue of COX-2 Class Effect," Jan. 15, 2005, p. 5).
COX-2 inhibitors were initially marketed because they were less likely to cause deadly peptic ulcers. People know how serious an MI or stroke is, but when they think of ulcers, they don't think about old people exsanguinating to death in the emergency department. They picture these Zantac commercials where the man wakes up with a tummy ache after eating too much pizza.
The hysteria is partly our fault. My generation of physicians believes that if the Food & Drug Administration approves something, it must be safe enough to dispense in gumball machines. After all, the real revolution in medicine is that medications--selective serotonin reuptake inhibitors, newer atypical antipsychotics, subcutaneous Lovenox, and so on--really are becoming safer and easier to use while they are becoming more effective. Safer medications have empowered us, but they have also made us complacent. This complacency rubs off on our patients.
Humans have an infinite ability to accept infinite risk. Nicotine comes with warnings that it can kill you, but it is because of those warnings that 7-Eleven clerks do not have to worry about malpractice coverage when shopping for really, really good life insurance. Patients accept the potential toxicity of statins because they want to avoid heart attacks without giving up chili dogs. They realize the risks not because doctors inform them, but because of a host of subtle cues: Doctors ask them if their muscles ache or if their eyes have turned yellow, and patients undergo periodic blood draws to "watch those liver enzymes." All of this powerfully communicates the risks posed by the pills we give them.
Patients feel betrayed by the COX-2 inhibitor debate because we dispensed Vioxx or Bextra with the same caution with which we hand out Metamucil packets. We feel even more guilty because we endangered patient lives for the sake of relieving their arthritis pain. After all, pain and immobility are not such a big deal, right?
The only way to preclude all risk is to stop prescribing all NSAIDs. Barring that, we can take reasonable precautions. We will weed out those COX-2 inhibitors that are particularly dangerous. If it becomes apparent that all COX-2 inhibitors as a class pose some risk, then before prescribing them, we may have to order screening tests such as baseline EKGs, lipid panels, or even stress tests; prescribe COX-2 inhibitors only for limited periods of time or for severe cases of pain; prescribe concomitant aspirin; or develop a risk reduction education program. ("If you develop crushing chest pain, stop taking your Celebrex and notify your physician.") These measures may not actually save lives, but they will give our patients a sense of control over their health.
Arnold Kim, M.D.
Irvine, Calif.
COPYRIGHT 2005 International Medical News Group
COPYRIGHT 2005 Gale Group
Contact
Home
A
Labetalol