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Nonrheumatologists wary of NSAIDs for kids.

Many physicians who care for children say that selective cyclooxygenase-2 nonsteroidal anti-inflammatory agents have equivalent or greater safety, efficacy, or tolerability and fewer side effects than do traditional NSAIDs. However, in the years since the voluntary withdrawal of rofecoxib and valdecoxib from the market, few practitioners aside from rheumatologists prescribe selective COX-2 NSAIDs for children, according to survey results.

The aim of the survey was to examine the prescribing habits of NSAIDs among pediatric medical and surgical practitioners, and to examine concerns and barriers to their use. A link to a 22-question Web-based survey that could be completed in 10-15 minutes was sent to 1,289 pediatricians, pediatric rheumatologists, sports medicine physicians, pediatric surgeons, and pediatric orthopedic surgeons Eighty-four e-mails were returned as "undeliverable."

Only 338 (28%) of the 1,205 e-mail recipients completed the surveys. The highest response rates were from pediatric rheumatologists (100 of 247, 40%) and the lowest from sports medicine specialists (12 of 106, 11%).

Indeed, one limitation of the study was that it was skewed to include a large percentage of pediatric rheumatologists, according to Dr. Deborah M. Levy, a pediatric rheumatologist at the Hospital for Sick Children in Toronto, and Dr. Lisa E Imundo, a pediatric rheumatologist at the Morgan Stanley Children's Hospital of New York--Presbyterian, Columbia University.

Of the pediatricians and pediatric subspecialists, 98% indicated they had prescribed an NSAID for a child. The most common reasons given for ever prescribing an NSAID were musculoskeletal pain, soft-tissue injury, fever, arthritis, fracture, and headache.

Nonrheumatologists frequently (more than once a week) prescribed ibuprofen, naproxen, and ketorolac, but they rarely prescribed any other NSAID. Rheumatologists used a wider variety of medications, most notably ibuprofen, diclofenac, indomethacin, naproxen, celecoxib, and rofecoxib.

About half of the respondents (164 of 330) had never prescribed a selective COX-2 NSAID. By specialty, 72% of pediatricians, 52% of orthopedic surgeons, 79% of pediatric surgeons, and 4% of rheumatologists had never prescribed a selective COX-2 NSAID. The most common reasons for prescribing a selective COX-2 NSAID were for arthritis, musculoskeletal pain, soft-tissue injury, and fracture. Use of these agents was more likely after failure of one or more traditional NSAIDS.

Responses from pediatric rheumatologists showed that certain adverse events were more common with conventional NSAIDs than with selective COX-2 agents. Specifically, abdominal pain (81% vs. 23%), epistaxis (13% vs. 2%), easy bruising (64% vs. 8%), headaches (21% vs. 1%), and fatigue (12% vs. 1%) were more common with traditional NSAIDs (n = 99) compared with the selective COX-2 medications (n = 95).

COX-2 NSAIDs were rated as equivalent or superior to traditional NSAIDs for safety (66%), pain relief (72%), relief of inflammation (74%), and tolerability (83%).

Eleven physicians reported that one or more patients had a cardiovascular event while taking an NSAID. The events were attributed to the patients' underlying diseases, and not to the use of either a traditional or selective COX-2 NSAID, according to the investigators.

Rofecoxib was voluntarily withdrawn from the market in September 2004 and valdecoxib was withdrawn in April of 2005, and these events affected physician prescribing habits. For pediatric rheumatologists, 57% said they prescribed selective COX-2 NSAIDs less frequently and 26% said they no longer prescribed them. Consequently, 44% increased their prescriptions of traditional NSAIDs.

Nine traditional NSAIDs (aspirin, etodolac, ibuprofen, indomethacin, ketorolac, meloxicam, naproxen, oxaprozin, and tolmetin) and one selective COX-2 NSAID (celecoxib) currently have Food and Drug Administration--approved pediatric indications. At the time of the survey, no COX-2 NSAID had a pediatric indication.

Disclosures: Dr. Levy received support through an independent research grant from Pfizer, manufacturer of valdecoxib. Dr. Imundo reported that she has no financial conflicts of interest.
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Author:Schonfeld, Amy Rothman
Publication:Family Practice News
Date:May 1, 2010
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