The analysis also showed an effect by race, with Hispanics and Asians having a significantly higher risk for GI events than whites. “I wouldn't make much of this until we look further,” he said.
But these findings begin to give physicians guidance on which patients need more expensive treatment with a coxib rather than cheaper treatment with a nonselective NSAID plus a proton pump inhibitor.
The findings suggest that an otherwise healthy 55-year-old patient with no history of gastritis who needs long-term NSAID treatment would face a relatively low risk for GI bleeds on a nonselective NSAID, Dr. Goldstein said. But in a similar, 65-year-old patient, “I'd use a coxib or add a proton pump inhibitor,” he said.
“Our findings show a clear advantage for the coxib, but the question is, is it worth it [the additional cost]? Is it economically feasible?” He said that a cost-effectiveness analysis should address these issues.
Dr. Goldstein also stressed that the results from CONDOR do not apply to patients with an elevated cardiovascular risk, including those on a chronic aspirin regimen. By design, CONDOR excluded patients on antiplatelet or anticoagulant drugs, including aspirin, and it also excluded patients with ischemic heart disease, heart failure, peripheral arterial disease, and cerebrovascular disease. “I can't comment on what's better for patients with cardiovascular disease. Cardiovascular events were not a significant finding in this trial.”
An editorial that accompanied the article published in the Lancet agreed that the CONDOR study is “the first large, double-blind, randomized clinical trial to assess upper and lower gastrointestinal events in patients needing chronic NSAID therapy.”
The authors of the editorial, Dr. Elham Rahme and Dr. Sasha Bernatsky, from McGill University in Montreal, called the 6-month duration of CONDOR “short” and “a drawback” that “hinders extrapolation to long-term treatment. The editorial also called “premature” the suggestion by Dr. Goldstein and his coauthors to revise existing recommendations for selecting NSAID therapy based on CONDOR's results (Lancet 2010; 376:146-8).
Dr. Goldstein replied that “it is premature to say [the CONDOR results] are important or unimportant. I'd say that we now have an opportunity to understand the importance” of lower GI events in patients on long-term NSAID treatment.