What is the effect of more restrictive prescribing guidelines on gastrointestinal complications?

Although COX-2 inhibitors may be slightly less likely to cause gastrointestinal (GI) complications, the overall increase in the use of nonsteroidal anti-inflammatory drugs (NSAIDs) seen after their introduction appears to have led to an overall increase in the number of GI complications in the population (not to mention the thousands of cardiovascular deaths attributed to this class of drugs). Although physicians complain about prescribing restrictions, sometimes for good reason, in this case they seem to be of benefit. (LOE = 2c)

Mamdani M, Warren L, Kopp A, et al. Changes in rates of upper gastrointestinal hemorrhage after the introduction of cyclooxygenase-2 inhibitors in British Columbia and Ontario. CMAJ 2006;175:1535-1538.  [PMID:17146090]

Ecologic

Government

Population-based

Although COX-2 inhibitors may provide a small absolute reduction in the number of serious GI complications compared with other NSAIDs, their high cost has led some insurance companies and governments to limit their use. In Canada, Ontario only required that the physician certify that the patient had failed therapy with 3 other NSAIDs or have significant GI disease to prescribe rofecoxib or celecoxib. British Columbia was much more restrictive, requiring a written request and approval by the drug plan via a "special authority process." Although the total use of NSAIDs (including COX-2 inhibitors) increased by only 29% over the expected rate after the introduction of COX-2 inhibitors in British Columbia, it increased by 64% in Ontario. In parallel with this increased overall use of NSAIDs, the researchers saw no change in admissions for GI bleeds in British Columbia but a statistically significant 26% increase in Ontario over expected rates. This amounts to approximately 2 additional admissions per 10,000 elderly Canadians.