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Am Fam Physician. 2004;69(3):595-597

Searchable Question

How effective are selective cyclooxygenase-2 (COX-2) inhibitors in reducing the symptoms of rheumatoid arthritis when compared with nonselective nonsteroidal anti-inflammatory drugs (NSAIDs)?

Evidence-Based Answer

The efficacy of COX-2 inhibitors is similar to that of nonselective NSAIDs in reducing the symptoms of rheumatoid arthritis. [Strength of Recommendation: A]

Evidence Summary

Four randomized, double-blind, controlled trials14 compared the COX-2 inhibitors celecoxib (Celebrex), etoricoxib (Arcoxia), and rofecoxib (Vioxx) with the NSAIDs naproxen (Naprosyn) and diclofenac (Voltaren). Both classes were found to have similar efficacy in nearly all outcomes in patients with rheumatoid arthritis (see the table on the following page). [References 1 through 4—Evidence level 1B]

Only one study1 found significant differences in any outcomes. Patients randomized to the higher celecoxib dosage were more likely to be rated as improved on the patient's and physician's global assessments of disease activity than patients given naproxen (number needed to treat: approximately 10).

A study5 comparing celecoxib with naproxen in the treatment of rheumatoid arthritis or osteoarthritis found similar efficacy between the treatment groups; however, the results were not analyzed separately by arthritis type. [Evidence level 1B]

Recommendations from Others

The London-based National Institute for Clinical Excellence (NICE) recommends the use of COX-2 inhibitors over other NSAIDs only in patients with rheumatoid arthritis who have a high risk of serious gastrointestinal adverse effects.6 NICE recommends against routinely prescribing COX-2 inhibitors in patients with cardiovascular disease (because of a potentially increased risk of myocardial infarction) and patients taking low-dose aspirin (because the gastrointestinal protection of COX-2 inhibitors is reduced).

Clinical Commentary

Physicians can assure their patients with rheumatoid arthritis who are at increased risk of gastrointestinal ulcers that COX-2 inhibitors are as beneficial as nonselective NSAIDs in ameliorating their symptoms. However, there is no clinical reason to routinely prescribe COX-2 inhibitors to patients who do not have an increased risk of ulcers.

OutcomeTrial, number of study participants, dosage comparison
Collantes, et al., 20024 (n = 445)Bombardier, et al., 20003 (n = 8,076)Emery, et al., 19992 (n = 665)Simon, et al., 19991 (n = 460)Simon, et al., 19991 (n = 465)
Etoricoxib (Arcoxia),* 90 mg once daily, versus naproxen (Naprosyn), 500 mg two times dailyRofecoxib (Vioxx), 50 mg once daily, versus naproxen, 500 mg two times dailyCelecoxib (Celebrex), 200 mg two times daily, versus diclofenac SR (Voltaren SR), 75 mg two times dailyCelecoxib, 200 mg two times daily, versus naproxen, 500 mg two times dailyCelecoxib, 100 mg two times daily, versus naproxen, 500 mg two times daily
Number of tender jointsNot assessed
Number of swollen jointsNot assessed
Patient's global assessment of painNot assessed
Functional disability
Patient's global assessment of disease activityBetter with celecoxib
Physician's global assessment of disease activityBetter with celecoxib
Percentage of patients meeting ACR-20 criteria†Not assessed
Withdrawals for lack of efficacy

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to https://www.fpin.org or email: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN’s Clinical Inquiries published in AFP is available at https://www.aafp.org/afp/fpin.

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