COX-2 inhibitors: What have I learned?

The controversy reinforced one surgeon’s commitment to finding alternatives to chronic systemic medications.

Issue: January 2005

ByDouglas W. Jackson, MD

Douglas W. Jackson, MD [photo] --- Douglas W. Jackson, Chief Medical Editor

I’m a bit disappointed in myself for being so susceptible to the unprecedented marketing hype around COX-2 inhibitors that influenced me to incorporate them into my practice as much as I did. You may recall my previous editorial noting that I’d never seen such an intense drug-marketing effort directed at orthopedic surgeons and their patients. Until my COX-2 inhibitors experience, I had been quite able to avoid new-product representatives and tried to base my drug choices on education and peer-reviewed experience.

With these new anti-inflammatory medications, our office was inundated with representatives offering free samples for our patients. Often three different reps covered our office for each drug. I had never received so many invitations to attend drug company-sponsored dinners, ball games and concerts, to become a consultant and meet at some resort, to speak on behalf of the product or to sponsor a course.

These marketing efforts exceeded anything I had ever seen. I often mentioned to the different sales reps that it would be much better to use all that promotion money to simply reduce the price of the drug. My practice was also beset by patients asking for the COX-2 inhibitors they had read about, seen on TV or heard about at a senior fair, or though a friend or relative. I had never received so many requests from patients for a specific drug.

During this time I was aware of the scattered reports of cardiovascular risks cropping up in connection with the drugs. Whenever I asked for an official response from the drug companies I received a defensive article or some other explanation refuting the latest report. I’d also be told the Food and Drug Administration was not recalling the drug and that we could count on the agency to take appropriate measures if there were ever a problem.

Treating local disease locally

Physicians must have the most current, objective information as they choose drugs and answer the questions from patients increasingly informed by direct-to-consumer advertising.

At the same time I was independently becoming much more of a proponent for treating local disease with local treatment. That is how I deal with my own musculoskeletal symptoms. I felt even more strongly that I should apply that approach to my patients because minimal systemic medications are the most effective way to avoid potential side effects. I much prefer programs, where possible, that include naturally occurring alternatives, strengthening supporting musculature, weight reduction, and activity modification or selection. These are the hallmark of my preferred approach.

I started asking all my patients on long-term COX-2 inhibitors, where convenient, to get refills from their primary care physicians, who already were monitoring patients’ other body systems for potential risks and complications. I also switched to using analgesics and NSAIDs on a limited, as-needed basis. As I alluded to above, I feel in my practice that long-term use of NSAIDs deserves more frequent monitoring of the liver, kidneys, the GI and cardiovascular systems then I typically do as their orthopedic surgeon. Of course orthopedic surgeons may choose to provide more frequent monitoring if they wish. (I have made a personal choice to handle the issue this way for my practice pattern based on occasional serious GI bleeds in the past and now the COX-2 controversy. There’s no need to be offended by my choice or to write to me about how orthopedic surgeons are able to do this just as well as any other physician.)

We always allow for exceptions. I certainly try not to stand in the way of a patient’s pain relief. I give them my perspective and may refer them to their primary care physician for long-term medication use if that is the only desired treatment. They know I am there to help them in the future if they want to consider an alternative. Having said that, I still have a number of chronic pain patients who depend on prescriptions and stay with me although I have recommended they go to, and in some cases have sent them to, a pain-management program.

The patients I enjoy caring for most want to be part of – even take control of – managing their orthopedic condition. They use me as a consultant and to provide them with care options. They will always learn from me that orthopedic surgery offers some great options for many who do not wish to live with chronic pain and a reduced quality of life. Part of each visit for me is reassuring patients that there are solutions out there if they cannot manage. The most frustrating patients for me personally to care for are those who simply want me to fix them and are not willing or disciplined enough to take an active role in choosing a solution. The COX-2 controversy, then, has made me rethink two things: the impact of marketing on my practice; and my commitment to alternatives to chronic systemic medications. The first point underscores the need for physicians to have the most current, objective information as we choose drugs and answer questions from patients increasingly informed by direct-to-consumer advertising. On the second point the controversy has reinforced my commitment to alternatives to using chronic systemic medications in my patients and myself.