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Cox-2 inhibitor

Arcoxia and Migraine: Risks?

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Recently some doctors have been prescribing Arcoxia (etoricoxib) for migraine.  But what’s the story behind this treatment?

Arcoxia and Migraine

Etoricoxib (brand names Arcoxia or Algix, Tauxib and Nucoxia) is a COX-2 selective inhibitor, a type of non-steroidal anti-inflammatory drug (NSAID).

COX-2: A brief history

COX-2 inhibitors were introduced to the public beginning in 1999.  It was hoped that the new type of NSAID would be easier on the stomach, as other NSAIDs such as ibuprofen can cause gastrointestinal issues.

But COX-2 inhibitors caused a storm of controversy, particularly in 2004-2005, and many were pulled off the market.  The concern was that the new drugs increased the risk of “cardiovascular events” – a particular concern for migraineurs, who already have an increased risk.

However, the risks varied depending on which COX-2 inhibitor was used.  There were also questions about risk vs. benefit in certain patients, and differences depending on dose and how long the patients took the drug.

Generally speaking, though Arcoxia was still suspect, it either didn’t raise the risk of heart problems at all or else raised the risk less than other COX-2 inhibitors such as Bextra (valdecoxib) and Vioxx (rofecoxib).

Today, Arcoxia is used in many countries around the world, though not in the United States, where the FDA has not received the data it requires to issue approval.  COX-2 inhibitors, including Arcoxia and Celebrex (celecoxib) are used in the treatment of headache and migraine, though it is still recommended that patients take the lowest dose possible for the shortest time possible.

Arcoxia and headache

Like other NSAIDs, Arcoxia is used to cut down pain and inflammation.  So it can be used like other NSAIDs depending on the patient.  There has been a special interest in using Arcoxia to prevent headache due to religious fasting (known often as “First of Ramadan Headache” or “Yom Kippur Headache”).  Patients take a dose right before fasting begins.  (See this study from 2011 and this from 2010.)

Arcoxia and Migraine

There is increased interest in using Arcoxia for migraine.  COX-2 inhibitors have been used as abortives, as short term correctives (ie taken for 10 days to break a cycle) or in some cases as a preventative.  There is also discussion about using an infusion of a COX-2 inhibitor to fight migraine, and this treatment has been used successfully in some cases.

Although etoricoxib helps to kill pain and fight inflammation, it may have unique benefits in migraineurs, fighting other symptoms.  A study last month suggested that COX-2 gene variants may raise the risk of migraine (see Cox-2 gene variants in migraine. )

Arcoxia and Migraine: Key Considerations

So if you’re thinking about trying Arcoxia for migraine, what are some of the things you should think about?

  • Discuss the benefits and risks with a doctor who knows your medical history (particularly history of heart conditions, liver or kidney disease).  COX-2 inhibitors have some unique properties – for example, patients from some racial groups absorb significantly more of the medication than others.  Discuss the dosage that is right for you, not just what it says on the bottle.
  • Make sure your doctor knows about other medications and supplements you may be taking.  Be sure to especially mention:  warfarin, medications related to heart conditions, lithium, hormone replacement therapies, magnesium, aspirin, and other NSAIDs.
  • Once again, do discuss heart risks with your doctor.  If you have a cardiologist, it would be wise to speak to her specifically.
  • Take Arcoxia with a glass of water, preferably at the same time each day.
  • Consider taking Arcoxia short-term, as a part of an overall treatment plan.
  • Arcoxia should not be taken during pregnancy.

Read more on Arcoxia here.  More about COX-2 inhibitors in general here.

The world decides the fate of the Cox-2s

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I hate to bring up the topic of Cox-2 inhibitors one more time, but I did want to let you know in brief what has been happening.  In various places in the world, the judgment has been much the same.  For example, Europe and the USA seem to be both deciding to allow Cox-2 inhibitors for now (these include brands like Dynastat, Prexige, Bextra, Celebrex and Arcoxia), but with restrictions on their use and labeling.  Many other countries, such as India and Australia have done the same thing.  In the USA’s FDA proceedings, both Bextra and Celebrex "passed", although the vote was extremely close in the case of Bextra.

And for the surprise twist, Vioxx itself may be reintroduced to the market.  It’s not that the risks on these drugs have suddenly vanished.  The question is, do the benefits to some patients outweigh the risks.  So be reminded again – educate yourself, talk to your doctor, keep track of your medical history and tell her about it, get a second opinion if you feel you need one, and don’t take drugs you don’t have to.  What you "have to" take is where the difference of opinion lies – but it’s your responsibility to make an informed decision.

Questions raised by the Cox-2 inhibitor frenzy…

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Cox-2 inhibitors continue to be at the forefront of the news, partly because of the huge economic impact that pulling them will have on some drug companies, partly because of the impact it will have on patients (they were generally prescribed for arthritis, but sometimes for headache), and partly because of the chance it gives us to look into the inner workings of how drugs are tested and promoted.

Many countries around the world have put out warnings about Cox-2 drugs as a class, restricted their use and or enforced new rules regarding what warnings must be on the labels.  It may be that in some places they will be banned altogether.  It will be interesting to see in the United States, for example, what the FDA decides.

Now that concerns have been brought to light, important questions are being asked that hopefully will not die out after this particular class of drugs is dealt with.  How does advertising effect the sale of a drug?  How and why should specific drugs be promoted to doctors?  How can drugs be trusted when so many studies are funded by the drug companies themselves?  What further testing should be required?

For us humble consumers, it highlights the need to be cautious about new drugs, to do our research, to ask questions, and to take warnings seriously.  Almost every drug has its drawbacks, and the same goes for many so called natural or non drug treatments.

For a little balance on the topic of Cox-2 inhibitors themselves, read this article from Dr Jasjit S. Bindra [link no longer available].  True, he himself is a former employee of the drug company Pfizer Inc., but he still makes some excellent points about the current state of research.

FDA Health Advisory – Bextra, Celebrex and Aleve

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Yesterday the American FDA issued a health advisory regarding the drugs Cox-2 drugs Bextra and Celebrex, and the NSAID naproxen.  Basically, they’re recommending that caution should be exercised with the drugs Bextra and Celebrex.  Recent studies seem to indicate that they may increase the risk of heart attack and stroke.  There is also concern about naproxen (popularly sold as Aleve, Anaprox,Naprosyn and others), which is not a Cox-2 drug like Bextra.  Recent studies show that naproxen may also increase risk of heart problems.  If you’re taking naproxen in any form for more than 10 days, talk to your doctor.  If you’re on any of these drugs and you have any history of heart trouble, talk to your doctor.  The FDA is awaiting further reviews on these drugs.  You can read yesterday’s health advisory put out by the FDA on their website.  WebMD has some excellent information on some of the recent studies involving Bextra.

Cox-2 Inhibitors – in the news again

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The information is coming in so fast that it’s hard to keep up to date! Many of you read in the last issue of HeadWay about emerging concerns about drugs such as Celebrex and Bextra. Now these drugs are getting more attention, and more studies are being done. You will notice some updates in this article about Cox2 Inhibitors, which will hopefully clear up some of your questions. Although the Vice-President of the US National Cancer Institute urges caution about jumping to conclusions about this study, I think we should continue to be cautious about using these drugs until more studies are completed.

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