COX 2 inhibitors cause less gastric bleeding than NSAIDs

A large case-control, hospital based study in Spain has confirmed that non-selective NSAIDs (non-steroidal anti-inflammatories) increase the risk of gastrointestinal bleeding compared with COX 2 (cyclo-oxygenase-2) inhibitors or aspirin. Ketorolac and piroxicam were associated with the highest age adjusted relative risk (8.0 (95% confidence interval 3.4 to 18.5) and 7.2 (4.8 to 10.7) respectively). The risk from diclofenac and ibuprofen was four to five times lower. The relative risk for rofecoxib was 2.1 (1.1 to 4.0), similar to that for the safest NSAID. Celecoxib, paracetamol, and concomitant use of a proton pump inhibitor with an NSAID presented no increased risk, suggesting that these should be used when avoiding bleeding is a priority. However, the advantage of COX 2 inhibitors is lost in patients taking low dose aspirin as a cardioprotective agent (which was 15% of the study population). Aspirin at analgesic doses was associated with as great a burden of bleeding as low dose aspirin, despite representing only about a third of all aspirin use. The authors suggest re-evaluating whether aspirin for analgesic purposes should remain freely available.