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Withdrawal Symptoms

Patients, Doctors Explore Alternatives to Vioxx For Arthritis Relief -- Very Carefully

By January W. Payne
Washington Post Staff Writer
Tuesday, November 23, 2004; Page HE01

Since Vioxx was withdrawn from the market in September, Olga Morales has been feeling the pain. Without medication, she said, her osteoarthritis feels like "having a constant toothache all over your body."

Since the heavily promoted pain medication was pulled by its manufacturer, Merck & Co., Morales has tried several different drugs.


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Taking eight daily doses of Advil -- a nonsteroidal anti-inflammatory drug, or NSAID -- gave her no relief. Several prescription NSAIDs caused flare-ups of her acid reflux disease and "chest pains like I was having heart attack," she said.

She now takes Daypro, another prescription NSAID. It doesn't make her ill, she said, but it doesn't work as well as Vioxx.

Vioxx "was great," said the 58-year-old Falls Church resident, who had taken the drug daily for three years. "It didn't make all of the pain go away. It just took the edge off, so I could function."

Morales is one of the millions of people with chronic osteoarthritis pain trying to figure out what to do in a post-Vioxx world. About 20 million people in the United States have taken Vioxx since 1999. Merck pulled the drug from the market after a study found heightened risk of cardiovascular side effects, including heart attack and stroke, among people taking the drug for at least 18 months. Previous studies had shown similar dangers as early as 2000.

Like Morales, most patients took Vioxx, in a class of drug known as COX-2 inhibitors, to treat osteoarthritis, the most common form of arthritis. About 20 million people have osteoarthritis -- characterized by erosion of surface cartilage (tissue that covers the ends of bones in a joint), which causes joint pain and limited movement. It is the most frequent cause of disability in adults, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

There is no cure for osteoarthritis. Some cases are so severe that joint replacement surgery is warranted, doctors said. Many drugs and other treatments remain available for the condition's short-term pain. But the many people who, like Morales, seek relief from its daily pain and stiffness do not have a clear alternative.

A new meta-analysis in the British Medical Journal (BMJ) recommends "only limited use" of NSAIDs for long-term treatment of knee osteoarthritis, citing questions about their effectiveness and safety. Of the 23 trials analyzed, all but one was short-term, evaluating the drugs' effects after two to 13 weeks. (The only longer-term study involved a drug not available in the United States.) A meeting of the Food and Drug Administration (FDA) drug safety advisory committee is planned for February to discuss the safety of the two other COX-2 drugs remaining on the U.S. market -- Bextra and Celebrex.

For some patients, doctors said, the benefits of taking those drugs may outweigh any risks.

"Arthritis hurts every day. These people have a problem every day," said David Borenstein, a rheumatologist at Arthritis and Rheumatism Associates, which has several locations in Maryland and the District. For them, Borenstein said, the possibility of long-term side effects needs to be weighed against greatly reduced pain today. His practice has switched some former Vioxx patients to Celebrex or Bextra.

Clinicians agree that drugs should not be seen as the only, or even the most effective, pain management tool. Exercise, physical therapy and pool exercise classes should be a key part of most osteoarthritis patients' regular routines. In many cases these measures can reduce or even eliminate the need for pain medications.

"The most important intervention people can have are exercise and maintaining their weight at a reasonable level," said Joan M. Bathon, a professor of medicine and the director of the Johns Hopkins Arthritis Center. Bathon said that the most common osteoarthritis patients are overweight women.

Morales, who works out six days a week and takes Pilates, yoga, spinning and dance classes, said exercise is an integral part of the management of her arthritis. "The biggest thing is to keep moving," she said, "because you feel better if you're moving."


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