Are COX-2 inhibitors a solution to problems associated with current oral analgesics? A revisit with a perspective of local need.2002 Malstrom et al. 69 Rofecoxib, 50mgCelecoxib, 200 mgCelecoxib, 400 mgIburofen, 400 mgPlacebo2002 Fricke et al. 70 Rofecoxib, 50 mg; followed byplacebo if requested at 4 hoursValdecoxib, 40 mg followed bysecond dose if requested at 4hoursPlacebo; followed by placebo ifrequested at 4 hours2004 Christensen et al. 71 Valdecoxib, 40 mgRofecoxib, 50 mgPlacebo2004 Zelenakas et al. 72 Lumiracoxib, 50 mgLumiracoxib, 100 mgIbuprofen, 400 mgPlacebo2004 Kellstein et al. 73 Lumiracoxib, 400 mgRofecoxib, 50 mgCelecoxib, 200 mgPlacebo2004 Chang et al. 74 Etoricoxib, 120 mgOxycodone, 10mg +paracetamol, 650 mgPlacebo2004 Malstrom et al. 75 Etoricoxib, 120mgNaproxen sodium, 550 mgParacetamol, 600mg + codeine60 mgPlacebo2004 Malstrom et al. 76 Etoricoxib, 60mgEtoricoxib, 120mgEtoricoxib, 180mg Etoricoxib,240 mgIbuprofen, 400 mgPlacebo1.2.3.1.2.1.2.1.2.1.2.1.2.3.1.2.3.1.2.3.4.Time to onset of analgesic effect and peakanalgesic effect were similar for rofecoxib 50mg and celecoxib 400 mg.Celecoxib 200mg inferior to rofecoxib withregard to onset and analgesic effectCelecoxib 400mg is superior to celecoxib 200mg with regard to analgesic effectValdecoxib superior to rofecoxib with regard toonset and analgesic effectValdecoxib exhibited longer duration of action.Valdecoxib superior to rofecoxib with regard toonset and analgesic effect at first 90 minutesAfter that, analgesic effect similar betweenvaldecoxib and rofecoxibLumiracoxib and ibuprofen were equivalentwith regard to onset and analgesic effectLumiracoxib exhibited longer duration of actionLumiracoxib and rofecoxib superior to celecoxibwith regard to onset and analgesic effectLumiracoxib superior to rofecoxib with regardto onsetOxycodone/paracetamol superior to etoricoxibwith regards to onsetEtoricoxib exhibited longer duration of actionthan oxycodone/paracetamolEtoricoxib superior to oxycodone/paracetamolwith regard to analgesic effectEtoricoxib and naproxen sodium were equivalentwith regard to analgesic effect and are superiot toparacetamol/codeineEtoricoxib, naproxen sodium and paracetamol/codeine were equivalent with regard to onsetEtoricoxib and naproxen sodium exhibited longerduration of action than paracetamol/codeineEtoricoxib 120 & 180 mg superior to etoricoxib60 mg and ibuprofen with regard to analgesiceffectEtoricoxib 120, 180 & 240 mg and ibuprofenwere equivalent with regard to onsetEtoricoxib exhibited longer duration of actionthan ibuprofenEtoricoxib 120 mg determined to be the minimumdose that had maximal efficacy.88
Ngeow / Ong2005 Malstrom et al. 77 Etoricoxib, 120mgParacetamol 600mg + codeine60 mgOxycodone, 10 mg +Paracetamol 650 mgPlacebo2005 Chalini andRaman 78Etoricoxib, 60 mg, twice dailyAceclofenac, 100mg, twice dailyNote: Unless stated, these were single-dose studies.1. Etoricoxib superior to paracetamol/codeine andoxycodone/paracetamol with regard to analgesiceffect2. Paracetamol/codeine and oxycodone/paracetamolsuperior to etoricoxib with regard to onset3. Etoricoxib exhibited longer duration of actionthan paracetamol/codeine and oxycodone/paracetamolEtoricoxib and aceclofenac were equivalent withregard to analgesic effectAll these COX-2 inhibitors are taken orally, exceptfor parecoxib, which is the only COX-2 inhibitor availablefor intravenous or intramuscular injection. Parecoxibis a prodrug of valdecoxib. Table 3 summarises thechronological outcomes of some of the current studies onthe efficacy of oral COX-2 inhibitors for the treatmentof acute dental pain. Studies purely on Rofecoxib arenot included since this analgesic is no longer of clinicalrelevance.The following discussion will concentrate soley oncelecoxib and etoricoxib as they are the COX-2 inhibitorscurrently available in Malaysia. As can be seen in Table3, a single dose of celecoxib (200 mg) provided analgesicefficacy similar to that of aspirin (650 mg), but inferior tothose of ibuprofen (400 mg) and naproxen (550 mg), asmeasured by time to onset of pain relief and peak pain relief.As a matter of fact, even at doses up to 400 mg, celecoxibwas still inferior to naproxen (550 mg). 65,67,68 Similarly,etoricoxib has been shown to have a comparable clinicalefficacy with traditional NSAIDs (Table 3). Etoricoxibwas equivalent to aceclofenac and naproxen sodium 75,78 butsuperior to ibuprofen, paracetamol/codeine and oxycodone/paracetamol with regards to analgesic effect. 74,75-77 Inaddition, etoricoxib exhibited longer duration of actionthan all these drugs.It has to be noted that all the drugs listed in thestudies in Table 3 were given postoperatively. Studieson the pre-emptive use of COX-2 inhibitors in otherspecialties, for example the use of etoricoxib as a preemptivemedication in orthopaedic surgery, 79 generalsurgery 80 and obstetric and gynaecological surgery 81 allshowed potential role of a COX-2 inhibitor as a preemptivemedication. Etoricoxib, for example was found tosignificantly decrease postoperative pain score, 79,81 reducetime to discharge 79 and reduce the need for post operativeopioids. 79-81 Such a potential application for use to controlpostoperative dental pain should be considered seriously.DISCUSSIONAre COX-2 inhibitors the oral analgesics of thefuture?The introduction of these selective COX-2inhibitors has allowed specific targeting of inflammatoryPG production while at the same time minimising adverseeffects such as gastrointestinal irritation, ulceration andbleeding problems. There is reasonable evidence showingthat these new drugs are preferable in patients whoare at an increased risk of developing serious upper-GI complications, in patients who take aspirin forcardiovascular comorbid conditions, and in those allergicto aspirin. Etoricoxib for example, has been recommendedas an alternative drug for patients who are hypersensitiveto NSAIDs. 82,83 Studies have confirmed that there is alack of cross-reactivity between etoricoxib and aspirin inaspirin-exacerbated respiratory disease (AERD), 84 thusmaking it a safe alternative for a patient who is allergicto aspirin and/or its associated drugs. Furthermore, COX-2 inhibitors may be given more safely than NSAIDs inperioperative settings because of their lack of impairmentof the blood-clotting. However, they are not recommendedfor patients who are pregnant or lactating. 85The high costs of COX-2 inhibitors, however, limittheir routine use during the short period of postoperativedental pain, which in most cases last between 2 to 4 days.This is because of the lack of increased risk to developingserious GI complications with the short-term use ofcost-saving NSAIDs. 86 Not to be forgotten, more recentwell designed randomised controlled clinical trials havedemonstrated that the apparent gastrointestinal advantageof selective COX-2 inhibitors appears to be outweighed bytheir potential for cardiovascular toxicity. 14,87Lastly, it has to be noted that adverse reactionto a COX-2 inhibitor had been reported; among whichwere anaphylactoid reaction, 88 fixed drug eruption andgeneralized erythema. 89 In specific, allergic reactions havebeen reported to celecoxib and valdecoxib as they have asulfonamide structure and are therefore, contraindicatedfor patients with known sulfa allergy. 90,91 Nevertheless,the number of patients developing adverse reactions isstill very low. For example, Weberschock et al. 92 in arecent systematic structured review found only 10 out of328 patients taking etoricoxib who developed adversereactions, all of which had been allergic/urticarial innature. Nevertheless, these newer designer oral analgesicsmust be used with caution.Based on current evidences, the authors are of theopinion that COX-2 inhibitors certainly have importantroles to play in the control of pain in dentistry, given the89