Several cyclo-oxygenase-2 inhibitors (COX 2 inhibitors) have been withdrawn from sale in many countries. The use of other drugs in this class is being limited by their potential to cause cardiac effects. As Kearney and colleagues show (p 1302), this concern is valid, since they have been associated with an increased risk of myocardial infarction with prolonged use as compared with placebo or other non-steroidal anti-inflammatory drugs.1

Have we lost a truly superior option? Probably not. Although COX 2 inhibitors were marketed as being less likely to cause gastrointestinal distress and ulceration, there is good evidence that other pharmacological and non-drug options may be reasonably effective, equally safe, and less costly.

COX 2 inhibitors rose to market prominence on the basis of premarketing and postmarketing studies showing less ulceration, on endoscopy, of the gastrointestinal tract. However, ulceration is neither intrinsically harmful nor a surrogate marker for harm associated with use of non-steroidal anti-inflammatory drugs (NSAIDs).2

Gastroduodenal damage found on endoscopy in clinical …