[Justification and indications for coxib therapy combined with gastro-protective agents]

IN THEORY: Combination use of a coxib with a gastro-protective agent does not appear justified since results of studies conducted on patients of all types demonstrated that the upper-digestive tract safety and tolerability profile of coxibs is good.

On the other hand, prescription-related descriptive data demonstrate that in real-life situations such a combination occurs in approximately 25% of cases. Two cases should be differentiated: in about half of cases, patients are receiving long-term therapy with a proton pump inhibitor (PPI) (for reflux oesophagitis, oesophagitis or dyspepsia) and when an NSAID is necessary, the prescribing physician logically turns to a coxib; in the other half of cases, it involves a true simultaneous co-prescription of a coxib and a gastro-protective agent (most often by far a PPI). Thus, it is only in 10-15% of patients that prescription of a coxib leads to prescription of a PPI. A SAFETY ATTITUDE: This approach can be justified by the physician's desire to be as cautious as possible in dealing a patient at high risk of GI disorders (elderly patients, previous history of digestive bleeding, co-prescription of aspirin and/or a steroid, co-morbidity) or in patients for whom the occurrence of GI bleeding would be very serious (i.e. a patient in poor condition due to multiple disorders, treatment with an oral anti-coagulant or heparin). In both cases, if the prescription of an NSAID cannot be avoided, it is therefore logical first to choose a coxib and second to prescribe simultaneously a gastro-protective agent.