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Physician prescribing preference plays a greater role than patient risk factors in prescribing COX-2 inhibitors

Patients with painful conditions, such as arthritis, often take nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). These NSAIDs include ibuprofen and selective cyclooxygenase (COX)-2 inhibitors, such as celecoxib (Celebrex) and rofecoxib (Vioxx). Although nonselective and selective NSAIDs are equally effective, nonselective NSAIDs cause gastrointestinal (GI) toxicity in some individuals. Selective COX-2 inhibitors have an average wholesale price that is 10 to 20 times higher than that of generic ibuprofen.

Patients who are at risk for GI toxicity from NSAIDs (older age, history of GI hemorrhage or peptic ulcer disease, or concomitant warfarin or oral glucocorticoid use) should be considered for the more expensive selective COX-2 inhibitors. However, physician prescribing preference more than patient risk factors for NSAID-associated GI toxicity seems to determine who will be prescribed selective COX-2 inhibitors, according to Daniel Solomon, M.D., M.P.H., and Sebastian Schneeweiss, M.D., Sc.D., of Brigham and Women's Hospital.

In a study supported in part by the Agency for Healthcare Research and Quality (HS10881), Dr. Schneeweiss and his colleagues examined factors influencing prescriptions for selective COX-2 inhibitors in a group of 28,190 Medicare beneficiaries enrolled in a pharmacy benefits program that reimbursed for both types of drugs without restrictions.

About one in six patients who filled a prescription for a selective COX-2 inhibitor had no recognized risk factor for NSAID-associated GI toxicity. Conversely, over three-quarters of nonselective NSAID users had at least one risk factor, and of this group, only 7 percent were also receiving gastroprotection with a proton pump inhibitor or misoprostol. Five established risk factors for NSAID-related GI toxicity explained almost none of the variation in prescribing. Adding other patient clinical and demographic characteristics to the model somewhat improved the predictive power of the model. However, when physician prescribing preference was included, the model had excellent discriminatory power between the two treatment groups.

See "Determinants of selective cyclooxygenase-2 inhibitor prescribing: Are patient or physician characteristics more important?" by Daniel H. Solomon, M.D., M.P.H., Dr. Schneeweiss, Robert J. Glynn, Ph.D., Sc.D., and others, in the December 15, 2003, American Journal of Medicine 115, pp. 715-720.

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