In Reply:—

Although we agree that this patient was at increased risk for development of gastropathy because of her older age and history of peptic ulcer disease, we did not believe this was a contraindication to the use of celecoxib. Although the package insert for celecoxib 1states that “significant upper GI bleeding” has occurred with celecoxib, the reported incidence was only 2 of 5,285 (0.04%) patients. In addition, a randomized controlled study 2that evaluated the safety and efficiency of 200–800 mg/day celecoxib compared with 1,000 mg/day naproxen or with placebo revealed no statistically significant differences in the incidence of gastroduodenal ulcers between the placebo group and any of the celecoxib groups (P > 0.40). In contrast, the incidence of ulceration in the naproxen group was significantly greater than in each of the other treatment groups (P < 0.001). Patients who were elderly or had a history of peptic ulcer disease were not excluded from this study. In fact, neither of these risk factors was associated with an increased risk for ulceration in any of the celecoxib groups. Therefore, we believed that celecoxib was a safer alternative to naproxen for our patient who received excellent analgesia from previous nonsteroidal antiinflammatory drug (NSAID) therapy.

In addition, we elected to administer omeprazole in conjunction with celecoxib therapy to facilitate gastric healing. The healing effectiveness of omeprazole does not appear to be compromised by the continued use of NSAIDs. 3Despite these measures, a gastric perforation still developed in our patient. As discussed in our case report, 4we believe that blocking the production of prostaglandins derived from COX-2 may be deleterious in the setting of a recent gastric mucosal injury. The previous cited studies 1,2that evaluated the risk of gastrointestinal tract ulceration during the administration of celecoxib did not include patients with a recent history (≤ 30 days) of peptic ulcer disease.

Although we believe COX-2 inhibitors are safer alternatives to standard NSAIDs in the presence of peptic ulcer disease, perhaps alternative analgesic therapy should be initiated in the presence of a recent gastroduodenal ulcer.

Celebrex (package insert): New York, Searle/Pfizer, 1993
Simon LS, Weaver AL, Graham DY, Kivitz AJ, Lipsky PE, Hubbard RC, Isakson PC, Verburg KM, Yu SS, Zhao WW, Geis GS: Anti-inflammatory and upper gastrointestinal effects of celecoxib in rheumatoid arthritis. JAMA 1999; 282:1921–8
Soll AH, for the Practice Parameters Committee of the American College of Gastroenterology: Medical treatment of peptic ulcer disease: Practice guidelines. JAMA 1996; 275:622–9
Reuben SS, Steinberg RB: Gastric perforation associated with the use of celecoxib. A nesthesiology 1999; 91:1548–9