For one patient, worries lead to better treatment

The 40-year-old patient swore by Vioxx as the only pill that could help her with her knee arthritis. She came to see me as soon as the drug was recalled. At first she didn’t want to give it up -- she even asked my secretary if I had a supply of samples stashed away.

But the drug now has been shown to nearly double a person’s risk of heart attack or stroke. The drug company representatives had come to remove it, and we wouldn’t have given the pills to her even if we’d had any.

In the examination room, she and I discussed her need for the arthritis pill. She wasn’t worried about her heart, realizing that her personal risk of heart attacks was very low and probably zero if the drug was stopped. However, I learned that she had been taking Vioxx far more often than I’d intended. I’d advised only sporadic use, but I now became aware that she had been taking it once every other day and sometimes daily.

Her usage wasn’t uncommon. After the drug was pulled from the shelves, many of my patients confessed that they’d been using the drug more frequently than I had recommended.

This realization is a silver lining to the Vioxx recall. It gives doctors a chance to revisit the issue of pain and arthritis and to compare the actual versus the intended use of a medicine.

In this patient’s case, I was more concerned about the long-term effects of the drug on her kidneys and liver than her heart. With extended use, nonsteroidal drugs such as Vioxx -- along with Celebrex (a competitor to Vioxx), naproxen and ibuprofen -- are associated with gradual, progressive damage to the tubules of the kidney.

I reexamined her knees and discovered that the ligaments were strong, and the arthritic changes didn’t appear severe. I encouraged her to revisit her orthopedist. We decided to re-image her knee with an MRI and send her to physical therapy, with the ultimate goal of diminishing the need for these medications.

In my consultation room, she asked me about switching to Celebrex. Though the drug has not been shown to cause heart disease, studies are ongoing. Further, though Celebrex has been heavily promoted as a drug that protects the stomach, it has not been proven to do that. The more than 100,000 people who are admitted to the hospital yearly from nonsteroidal bleeding include many users of the Cox-2 inhibitors, despite the marketing claims.

Despite the patient’s esophageal reflux, she didn’t have proven gastritis or ulcer, so I was reluctant to automatically switch her to Celebrex. I might have done so previously, but the Vioxx recall had made me more wary of all the newest arthritis drugs, regardless of what the drug reps said to try and influence me.

At the same time, I was reluctant to encourage her to take over-the-counter alternatives such as Advil or Aleve, because then I would have no control over how much she took. The Vioxx situation already had brought to light that patients overutilized the nonsteroidal drugs. Over-the-counter substitutes made overuse too easy.

We settled on naproxen, a proven nonsteroidal at least as effective as any of the others. I also gave her a prescription for Prevacid (a proton pump inhibitor) that has been proven to protect the stomach lining from the effect of nonsteroidal anti-inflammatory drugs.

Because of her mild reflux, I suggested she take the Prevacid if the naproxen irritated her stomach.

A few days later, she happily reported that the naproxen had worked just as well as the Vioxx, and she had tolerated it well.

She repeated her intention to take it sparingly, and to follow through with the rest of the plan.

Initially worried about her, I now realized that her concern over stopping Vioxx had transformed her plan of treatment, making it better and more comprehensive.

I understood her condition better, and she felt cared for.

For physicians, the Vioxx recall is a good juncture to review whether patients need this medicine and at what frequency.

This reassessment doesn’t apply only to Vioxx, but to all flashy new treatments that come along to replace what already works.

Sometimes older, equally effective medications have been too quickly bypassed to get to the newer models.

Some patients won’t need to take such drugs as often as they’ve been advised. Others won’t need them at all.

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Marc Siegel is an associate professor of medicine at New York University School of Medicine. He can be reached at marc@doctorsiegel.com.