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Safety of Cyclooxygenase-2 Inhibitors in Osteoarthritis: Outcomes of a Systematic Review and Meta-Analysis

Curtis, Elizabeth; Fuggle, Nicholas; Shaw, Sarah; Spooner, Laura; Ntani, Georgia; Parsons, Camille; Corp, Nadia; Honvo, Germain; Baird, Janis; Maggi, Stefania; Dennison, Elaine; Bruyère, Olivier; Reginster, Jean-Yves; Cooper, Cyrus

Safety of Cyclooxygenase-2 Inhibitors in Osteoarthritis: Outcomes of a Systematic Review and Meta-Analysis Thumbnail


Elizabeth Curtis

Nicholas Fuggle

Sarah Shaw

Laura Spooner

Georgia Ntani

Camille Parsons

Germain Honvo

Janis Baird

Stefania Maggi

Elaine Dennison

Olivier Bruyère

Jean-Yves Reginster

Cyrus Cooper


OBJECTIVE: Our aim was to assess the safety of cyclooxygenase-2 (COX-2) inhibitors in the management of osteoarthritis (OA) in a systematic review and meta-analysis of randomized, placebo-controlled trials. METHODS: A comprehensive literature search was undertaken in the databases MEDLINE, Cochrane Central Register of Controlled Trials (Ovid CENTRAL) and Scopus. Randomized, double-blind, placebo-controlled, parallel-group trials that assessed adverse events (AEs) with COX-2 inhibitors in patients with OA were eligible for inclusion. Two authors appraised titles, abstracts and full-text papers for suitability and then assessed the studies for random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data and selective outcomes reporting. The primary outcomes of interest were gastrointestinal disorders, cardiac disorders, vascular disorders, nervous system disorders, skin and subcutaneous tissue disorders, hepatobiliary disorders, renal and urinary disorders, as well as overall severe and serious AEs, drug-related AEs and mortality. Secondary outcomes were withdrawals due to AEs (i.e. the number of participants who stopped the treatment due to an AE) and total number of AEs (i.e. the number of patients who experienced any AE at least once). RESULTS: Database searches identified 2149 records from which, after exclusions, 40 trials were included in the meta-analysis. The use of COX-2 inhibitors in OA was associated with a significant increased risk of drug-related AEs compared with placebo (relative risk (RR) 1.26, 95% CI 1.09-1.46; I2?=?24%). The risk of upper gastrointestinal complications (including dyspepsia, gastritis and heartburn) was significantly increased with COX-2 inhibitors versus placebo (RR 1.19, 95% CI 1.03-1.38; I2?=?0%), particularly for abdominal pain, which increased by 40% with COX-2 inhibitors (RR 1.40, 95% CI 1.08-1.80; I2?=?0%). The risk of hypertension increased by 45% overall (RR 1.45, 95% CI 1.01-2.10; I2?=?25%); however, when rofecoxib was removed from the analysis the risk of hypertension in the COX-2 inhibitor group was no longer significant (RR 1.21, 95% CI 0.80-1.83; I2?=?20%). The overall risk of heart failure and edema was increased by nearly 70% with COX-2 inhibitors versus placebo (RR 1.68, 95% CI 1.22-2.31; 0%) and this level of risk did not change appreciably when rofecoxib was excluded (RR 1.67, 95% CI 1.21-2.29; 0%). CONCLUSIONS: In our analysis, COX-2 inhibitors were associated with an increased risk of upper gastrointestinal AEs, especially abdominal pain. We also found an increased risk of cardiovascular AEs with COX-2 inhibitors, namely hypertension, heart failure and edema.


Curtis, E., Fuggle, N., Shaw, S., Spooner, L., Ntani, G., Parsons, C., …Cooper, C. (2019). Safety of Cyclooxygenase-2 Inhibitors in Osteoarthritis: Outcomes of a Systematic Review and Meta-Analysis. Drugs and Aging, 36, 25 - 44.

Journal Article Type Review
Acceptance Date Apr 1, 2019
Online Publication Date May 9, 2019
Publication Date May 9, 2019
Publicly Available Date May 26, 2023
Journal Drugs & Aging
Print ISSN 1170-229X
Publisher Springer Verlag
Peer Reviewed Peer Reviewed
Volume 36
Pages 25 - 44
Keywords osteoarthritis
Publisher URL


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